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

 
We decided that the Plan does not have to reimburse you for the oral exam (D0120) and prophylaxis (D1110) 
provided on October 26, 2021. 
 
You asked the Plan to reimburse you for the dental services. You say that you were under the impression that 
your dentist had been opted back into Medicare on March 7, 2021. You also say that you should be reimbursed for the services in this case. 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. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and the dental services are listed as 
covered, payment cannot be made to a provider that has opted out of Medicare. The record shows that the 
providers opt out status is effective until March 7, 2022. Therefore, we decided that the Plan does not have to 
reimburse you for the oral exam (D0120) and prophylaxis (D1110) provided on October 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on December 3, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code G0483 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0483 is definitive drug testing, 22 or more drug classes. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the file shows that 16 drug 
classes were tested. Based on this information, we decided that Medicare rules for coverage of these services 
have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on 
December 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options, power seat elevation, and upgraded electronics coded with K0861, E2361, E1028, E1007, E2300, 
E2620, E0955, E1028, E1012, E0953, E2377, E2311, E2313 and E2607. 
 
You asked the Plan to pre-approve the power wheelchair and upgraded electronics. You say that you are 
requesting reconsideration of the medical necessity of all the components of this K0861 required by the 
enrollee to meet his medical, functional and mobility needs throughout the day in his home. The Plan denied 
your request. The Plan says the requested power wheelchair with multiple power options and upgraded 
electronics are not medically necessary. the seat elevator (E2300) does not serve a medical purpose so is not 
covered. A group 3 power wheelchair with no power options can be approved if requested. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair and upgraded 
electronics. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found in this case, the enrollee has a neurologic disorder with 
functional deficits.  Criteria for a power wheelchair are met. The documentation does not indicate that the 
enrollee has any pressure injuries or requires intermittent catheterization of the bladder that would necessitate 
power tilt or recline. The requested electrical accessories are not medically necessary as the member does have 
use of the upper extremity and can operate and control the power options using the switches that are included in 
the basic wheelchair. The currently requested group 3 power wheelchair with multiple power accessories is not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the power wheelchair and upgraded electronics have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options, power seat elevation, and upgraded electronics coded with K0861, E2361, E1028, E1007, E2300, 
E2620, E0955, E1028, E1012, E0953, E2377, E2311, E2313 and E2607.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on December 2, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on December 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pain management services rendered on June 16, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code G0283 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0283 is electrical stimulation (unattended), to one or 
more areas for indication(s) other than wound care, as part of a therapy plan of care. The definition of code 
98928 is osteopathic manipulative treatment, 7-8 body regions. The definition of code 20611 is arthrocentesis, 
aspiration and/or injection, major joint or bursa with ultrasonic guidance. The definition of code J3301 is 
injection of triamcinolone acetonide, 10 mg. The definition of code 80176 is assay of lidocaine. 
 
We find that CPT codes G0283, 98928, 20611, J3301, and 80176 are not supported in the medical record. 
Specifically, there is no documentation of unattended electrical stimulation to one or more areas for indications other than wound care to support code G0283. There is no documentation of osteopathic manipulative 
treatment of 7-8 body regions to support code 98928. There is no documentation of arthrocentesis with 
ultrasonic guidance to support code 20611. There is no documentation of an injection of 10 mg of 
triamcinolone acetonide to support code J3301. There is no documentation of an assay of lidocaine to support 
code 80176. 
 
Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for the pain management services rendered on June 
16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient consultation (99254) provided on July 26, 2021. 
 
You asked the Plan to pay for the inpatient consultation. You say that this service was billed appropriately. The 
Plan denied your request. The Plan says this code is not valid 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 CPT code. 
 
We find that CPT code 99254 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code 99254 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of the inpatient consultation have not been met. Therefore, we decided that the Plan does not have to 
pay for the inpatient consultation (99254) provided on July 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician interpretation and report of a molecular 
pathology procedure (G0452) provided on October 1, 2021. 
 You asked the Plan to pay for the physician interpretation and report of a molecular pathology procedure. You 
say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan 
says an edit exists between CPT codes G0452 and 81270, 81279, 81219, and 81338. 
 
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 G0452 is a column II code to column I codes 81270, 81279, 81219, 
and 81338; however, G0452 TC 59 and G0452 26 59 was billed with a modifier.  
 
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 the physician interpretation and report of a molecular 
pathology procedure. Our reviewer says that CPT code G0452 does not meet criteria for billing or 
reimbursement consideration. Our reviewer found the documentation does not support modifier 59. Per CMS 
this service must be requested by the patient's attending physician, must result in a written narrative report and 
requires the exercise of medical judgement by the consultant physician. This criteria is not supported in the 
documentation submitted, and therefore 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 the physician interpretation and report of a molecular pathology procedure have 
not been met. Therefore, we decided that the Plan does not have to pay for the physician interpretation and 
report of a molecular pathology procedure (G0452) provided on October 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from the 
LTACH level of care. The Plan denied your request. The Plan says the enrollee's needs are met in the current 
facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where he/she is currently receiving care. All medically necessary care is being provided in the 
current acute care facility. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sleeve gastrectomy (43775) and inpatient hospital 
admission. 
 
You asked the Plan to pre-approve sleeve gastrectomy (43775) and inpatient hospital admission. You say that 
the requested services are medically necessary. The Plan denied your request. The Plan says the enrollee does 
not meet coverage criteria for the requested services. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. There are also specific LCD criteria defining a reasonable and necessary sleeve 
gastrectomy as noted in the Medicare rules section of this letter. 
 
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 sleeve gastrectomy (43775) and 
inpatient hospital admission. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the records indicate that the enrollee has 
tried and failed medically supervised weight loss programs in the past. The medical record shows that the 
enrollee was evaluated by a mental health provider. During the mental health evaluation, she was noted to be 
an emotional eater and used food to cope with depression and past trauma. The recommendation from the 
mental health provider shows that due to a history of depression and reports of using food as a coping skill 
during times of emotional distress, 6 months of outpatient counseling is recommended to address depressive 
symptoms and develop healthy coping skills. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sleeve gastrectomy (43775) and inpatient hospital admission have not been met. 
Therefore, we decided that the Plan does not have to pre-approve sleeve gastrectomy (43775) and inpatient 
hospital admission.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on January 6, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the services provided. You say that routine drug testing is necessary to monitor 
the use of prescriptions. The Plan denied your request. The Plan says the services were not urgent, emergent, or 
approved in advance. 
 
 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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the drug testing services provided on January 6, 2022, by an out-of-network 
(OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on March 2, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says if a laboratory assays two or more genes in a patient in parallel, then those two or more genes 
will be considered part of the same panel. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay 
for laboratory services provided to the enrollee on March 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on July 18, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says one code must 
be submitted for the panel. 
 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 file shows that the pharmacogenetics testing panel was billed with multiple codes. If a single procedure is 
performed, only one code with one unit of service may be reported for the procedure. Based on this 
information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, 
we decided that the Plan does not have to pay for the lab testing services provided on July 18, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve SNF admission. You say that the enrollee will require continued therapy to 
address mobility dysfunction. The Plan denied your request. The Plan says the SNF admission is not medically 
necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The 
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on 
an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants for teeth #s 10, 23, and 26. 
 
You asked the Plan to pre-approve the requested dental implants. You say that you have been taking antibiotics 
for weeks due to an infection which could spread to your heart. You feel that this is cheaper than continuing to 
treat the infection. The Plan denied your request. The Plan says implants are not covered under your dental 
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 pre-approve 
dental implants for teeth #s 10, 23, and 26.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services (97110) provided on October 28, 
2021. 
 You asked the Plan to pay for physical therapy. You say that these services were medically necessary and were 
billed correctly. The Plan denied your request. The Plan says these services are not supported as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the physical therapy services are not supported in the medical record as billed. Specifically, the 
documentation shows that this claim was billed by a Nurse Practitioner but the therapy services at issue were 
rendered by a Physical Therapy Assistant. There is no indication that the Nurse Practitioner was present on site 
while the therapy services were being rendered. The incident-to requirements have not been met in this case. 
Based on this information, we decided that Medicare rules for coverage of physical therapy have not been met. 
Therefore, we decided that the Plan does not have to pay for physical therapy services (97110) provided on 
October 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and panoramic 
radiographic image (D0330), provided by Department of Health Services on April 5, 2021. 
 
You asked the Plan to pay for a comprehensive oral evaluation and panoramic radiographic image. You say 
that you would like the Plan to pay for this. The Plan denied your request. The Plan says services provided out-
of-network 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. The Plan covers a 
comprehensive oral evaluation and panoramic radiographic image when the services are provided by a 
participating provider. 
 We looked at the file and Medicare rules. The rendering provider is out-of-network. Based on this information, 
we decided that the Plan's rules for coverage of a comprehensive oral evaluation and panoramic radiographic 
image have not been met. Therefore, we decided that the Plan does not have to pay for a comprehensive oral 
evaluation (D0150), and panoramic radiographic image (D0330), provided by Department of Health Services 
on April 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implant services (D6078, D6010). 
 
You asked the Plan to pre-approve dental implant services. You say that this is medically necessary. The Plan 
denied your request. The Plan says these requested dental services are not covered by the Plan's supplemental 
dental 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 pre-approve 
dental implant services (D6078, D6010).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services rendered on January 18, 2022 to 
January 27, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. The file shows that the 
chiropractor billed code 97110 (therapeutic exercises), which is not covered from a chiropractor. Therefore, we 
decided that the Plan does not have to pay for the chiropractic services rendered on January 18, 2022 to January 
27, 2022.