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

We decided that the Plan does not have to pay for a panoramic radiographic image (D0330), intraoral - periapical first radiographic image (D0220), comprehensive oral evaluation (D0150), mandibular partial denture (D5214), complete denture - maxillary (D5110), reline complete maxillary denture (direct) (D5730), and incisional biopsy of oral tissue-soft (D7286) provided on January 10, 2022, to March 16, 2022.

You asked the Plan to pay for the dental services. You say that you are asking for reimbursement due to the pain you suffered. The Plan denied your request. The Plan says your benefit for the requested services have already been exhausted or are not covered by the Plan'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 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 the comprehensive oral evaluation (D0150), and panoramic radiographic image (D0330), and was exhausted on date of service September 17, 2020.

The mandibular partial denture (D5214), and complete denture - maxillary (D5110) was exhausted on November 18, 2020.

The reline complete maxillary denture (direct) (D5730) was exhausted on date of service July 6, 2022.

The intraoral - periapical first radiographic image (D0220) was exhausted on date of service October 6, 2022.

Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image (D0330), intraoral - periapical first radiographic image (D0220), comprehensive oral evaluation (D0150), mandibular partial denture (D5214), complete denture - maxillary (D5110), reline complete maxillary denture (direct) (D5730), and incisional biopsy of oral tissue-soft (D7286) provided on January 10, 2022, to March 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT scan of the heart.

You asked the Plan to pre-approve CT scan of the heart. You say that you would like reconsideration because the services are medically necessary. The Plan denied your request. The Plan says a CT scan of the heart 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 heart. Our reviewer says that the requested CT scan of the heart is not medically necessary. Our physician reviewer found there is no indication in the documents demonstrating a significant benefit of CT imaging of the heart with quantitative evaluation of coronary calcium in guiding optimal management. As such, CT imaging of the heart without contrast material with quantitative evaluation of coronary calcium is considered experimental/investigational for the evaluation and management of your medical condition.

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 heart have not been met. Therefore, we decided that the Plan does not have to pre-approve a CT scan of the heart.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - periapical each additional radiographic image (x1) 
(D0230) and intraoral - periapical first radiographic image (D0220) provided on November 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed the services prior to receiving 
chemotherapy. The Plan denied your request. The Plan says your benefit for the requested item or service 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. This benefit includes the 
requested intraoral - periapical each additional radiographic image (D0230) and intraoral - periapical first 
radiographic image (D0220) but is limited to one procedure code per calendar year. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received one covered D0230 on November 17, 2022; therefore, your benefit was exhausted. 
Therefore, we decided that the Plan does not have to pay for intraoral - periapical each additional radiographic 
image (x1) (D0230) and intraoral - periapical first radiographic image (D0220) provided on November 17, 
2022.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory services coded 81479 provided on August 26, 2022.

You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says that the services are not payable as billed.

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. Review of the file shows that the Plan mentions Medicare historical pricing is requested as the rationale for denial. In the justification section, the Plan mentions that the claim is filed untimely. However, neither of these rationales are correct. The documentation shows that this claim was submitted timely. No other Plan denial rationale was provided. The Plan did not substantiate their denial. Therefore, we decided that the Plan has to pay for the laboratory services coded 81479 provided on August 26, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, 
E2313, E2377). 
 
You asked the Plan to pre-approve additional power wheelchair accessories. You say that these items are 
necessary The Plan denied your request. The Plan says this is not medically necessary. 
 
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 additional power wheelchair 
accessories. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has adequate upper body strength to manage 
standard switches on a power wheelchair. 
 
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 power wheelchair accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, 
E2377).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 63012, 63056, and 63057 billed for date of 
service June 13, 2022. 
 
You asked the Plan to pay for the billed services. You say that the report substantiates the services. The Plan 
denied your request. The Plan says the services are considered inclusive. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The medical records provided do not show that procedure codes 63012, 63056 and 63057, billed with the -59 
modifier, were distinct procedural services. The records do not show that these services were performed at 
different anatomical sites or at different encounters. Based on this information, we decided that Medicare rules 
for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 63012, 63056, and 63057 billed for date of service June 13, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Next Generation Sequencing (NGS) - 0250U - 
Oncology (solid organ neoplasm), targeted genomic sequence DNA analysis of 505 genes, interrogation for 
somatic alterations (SNVs [single nucleotide variant], small insertions and deletions, one amplification, and 
four translocations), microsatellite instability and tumor-mutation burden. 
 
You asked the Plan to pre-approve genetic testing. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet requirements for approval. 
 
The Plan follows Medicare rules. Medicare rules say that genetic testing can be covered if certain 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 genetic testing. Our reviewer says that 
the enrollee does not meet coverage criteria. Our physician reviewer found the documentation does not support 
that the enrollee has recurrent, relapsed, refractory, metastatic, or advanced (stages III or IV) cancer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Next Generation Sequencing (NGS) - 0250U - Oncology (solid organ neoplasm), targeted 
genomic sequence DNA analysis of 505 genes, interrogation for somatic alterations (SNVs [single nucleotide 
variant], small insertions and deletions, one amplification, and four translocations), microsatellite instability 
and tumor-mutation burden.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum Assisted Socket System (VASS). 
 
You asked the Plan to pre-approve a VASS. You say that the item is medically necessary. The Plan denied your 
request. The Plan says this item is considered experimental. 
 
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 a VASS. Our reviewer says that the 
requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found 
the literature reviewed indicates that further research is needed with clinical trials that recruit larger sample 
sizes and report long-term outcome data for the requested vacuum suspension 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 a VASS have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a vacuum Assisted Socket System (VASS).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services rendered from January 14, 2022, to January 
16, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this should be paid for. The Plan 
denied your request. The Plan says that charges for or in connection with services or supplies that are, as 
determined by the plan, considered to be experimental or investigational are excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the review indicates that the record showed that at the time of inpatient admission the 
admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for inpatient hospital services rendered from January 14, 2022, to January 16, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99070 billed for date of service October 19, 
2022. 
 
You asked the Plan to pay for procedure code 99070. The Plan denied your request. The Plan says procedure 
code 99070 is 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 code 99070 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99070 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99070 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99070 billed for date of service October 19, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the services are not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found Ongoing home 
health services are not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341 and 88342 billed for date of service 
June 27, 2022. 
 You asked the Plan to pay for procedure codes 88341 and 88342. You say that the codes are payable as billed. 
The Plan denied your request. The Plan says this code is included in the facility payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient. Per the Physician Fee 
Schedule, there is a Professional/Technical indicator of 1 for CPT codes 88341 and 88342. This means there is 
both a professional and technical component for the CPT codes. In this case, an appropriate modifier to indicate 
the professional component has not been billed with the CPT codes. 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 88341 and 88342 billed for date of service June 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the therapeutic injections provided from April 20, 
2021, to October 5, 2021. 
 
You asked the Plan to reimburse you the injections. You say that you paid $11,946.49 out-of-pocket for these 
services. You also say that you would like to get some of your money back. The Plan denied your request. The 
Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made 
for services performed by a provider that has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for 
the therapeutic injections provided from April 20, 2021, to October 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine eye exam provided on November 18, 2022 
 You asked the Plan to pay for the routine eye exam. You say that the claim should be paid because you have 
coverage. The Plan denied your request. The Plan says the benefit has been exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers a routine eye exam once a year. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid for a routine eye exam on June 6, 2022, 
which exhausted the benefit. Based on this information, we decided that the Plan's rules for coverage of the 
routine eye exam have not been met. Therefore, we decided that the Plan does not have to pay for the routine 
eye exam provided on November 18, 2022
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99285 billed for date of service October 31, 2022. 
 
You asked the Plan to pay for code 99285. You say that the medical records support the billing of code 99285. 
The Plan denied your request. The Plan says code 99285 was not supported by the medical record and was 
therefore down coded. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. 
 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 code 99285. Our reviewer says that code 99285 is not 
supported by the medical record. Our reviewer found the patient presented with right upper abdominal pain that 
had been present off and on for a year; the symptoms were severe on the day of presentation with loss of 
appetite but reportedly no nausea, vomiting, diarrhea or fever. A complete review of systems was otherwise all 
negative. The patient had no fever, and all vital signs were stable. Her abdomen was soft and non-distended 
with "mild" tenderness. Her laboratory data were largely negative, and her abdominal ultrasound showed 
possible cholecystitis. Oral antibiotics and outpatient follow-up with surgery was recommended. Records did 
not document medical decision making of high complexity with a high risk of complication with immediate 
significant threat to life or physiologic function to meet criteria for code 99285.   
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99285 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99285 billed for date of service October 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a catheter ablation. 
 
You asked the Plan to pre-approve a catheter ablation. You say that the service is medically necessary. The 
Plan denied your request. The Plan says this is not a covered service. 
 
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 a catheter ablation. Our reviewer says 
that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documented atrial fibrillation. 
 
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 catheter ablation have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a catheter ablation.