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

 
We decided that the Plan does not have to pay for the dental services (D0150 and D0274) provided on January 
11, 2022. 
 
You asked the Plan to pay for dental codes D0150 and D0274. You say that you would like the Plan to 
reconsider your request. The Plan denied your request. The Plan says under the Plan's supplemental dental 
benefit, you are covered for dental code D0150 once every three years and dental code D0274 once every year. 
The Plan says payment was made for both codes when you received these services on May 7, 2021. 
 
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. 
 
We looked at the file and the Plan's contract. The Plan's covers dental code D0150 once every three years and dental code D0274 once every year. The file shows that payment was made by the Plan for both codes when 
you received these services on May 7, 2021. Therefore, we decided that the Plan does not have to pay for the 
dental services (D0150 and D0274) provided on January 11, 2022.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition, endoskeletal, knee-shin system, stance 
flexion feature (L5845). 
 
You asked the Plan to pre-approve an addition, endoskeletal, knee-shin system. You say that the requested 
device/item is medically necessary. The Plan denied your request. The Plan says the requested part is 
unbundled from the approved knee and cannot be requested separately. 
 
The Plan must follow Medicare rules. Medicare rules say the beneficiary may qualify for an upgraded knee-
shin system depending on their assigned K-level modifier (K0-K4). 
 
We looked at the file and Medicare rules. The records show that the enrollee was approved for an L5814 and 
paired with an L5850. The records also show that a single addition code can fully describe a complete knee-
shin system and thus the use of two codes from the list would be considered incorrect coding (unbundling).  
Based on this information, we decided that Medicare rules for coverage of an addition, endoskeletal, knee-shin 
system have not been met. Therefore, we decided that the Plan does not have to pre-approve an addition, 
endoskeletal, knee-shin system, stance flexion feature (L5845).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 18, 2021. 
 
You asked the Plan to pay for the services provided. You say that the referring physician provided information 
in belief that no complications would arise. The Plan denied your request. The Plan says there are no modifiers 
that are allowed with the code pair. 
 
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 84480 is a column II code to column I code 84481 with a modifier 
indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for the lab services 
provided on June 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus gene panel provided on November 28, 2021, 
billed with 13 different testing codes. 
 
You asked the Plan to pay for the Tempus panel as billed. You say that this was medically necessary testing 
that is proven clinically useful by multiple studies. The Plan denied your request. The Plan says this is not 
billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing 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. The testing provided is a next-generation sequencing panel for which 
a single panel code was not used. Based on this information, we decided that Medicare rules for coverage of the Tempus panel as billed have not been met. Therefore, we decided that the Plan does not have to pay for the 
Tempus gene panel provided on November 28, 2021, billed with 13 different testing codes.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the percutaneous laminotomy/laminectomy (0275T) provided 
September 29, 2021. 
 
You asked the Plan to pay for the outpatient procedure. You say that you are appealing for payment of code 
0275T. Attached is print out from Medicare website which shows Medicare would cover this code. The Plan 
denied your request. The Plan says that the service is not covered by this payer/contractor. 
 
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. the Plan has not provided any evidence that the enrollee has additional insurance 
that would act as their primary. The case file also included the Plan's approved prior authorization of the 
services dated September 22,2021 which also did not indicate that there is another payer. Therefore, we 
decided that the Plan has to pay for the percutaneous laminotomy/laminectomy (0275T) provided September 
29, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the PET with concurrently acquired CT for attenuation 
correction and anatomical localization imaging; skull base to mid-thigh (CPT code 78815). 
 
You asked the Plan to pre-approve the PET scan. You say that you were advised that you need to see a 
specialist to get a PET scan as soon as possible. The Plan denied your request. The Plan says there is no 
physician order for the PET scan. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the PET scan have not been met. There is no physician order for 
the PET scan. Therefore, we decided that the Plan does not have to pre-approve the PET with concurrently 
acquired CT for attenuation correction and anatomical localization imaging; skull base to mid-thigh (CPT code 
78815).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on March 30, 2021. 
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this testing is correct, because this testing was not 
billed with the appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for genetic testing provided on March 30, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve myocardial perfusion imaging, tomographic (SPECT) (including 
attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, 
additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) 
and/or redistribution and/or rest reinjection (CPT code 78452). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary, and the enrollee also 
needs cardiac clearance for cataract surgery. The Plan denied your request. The Plan says that the Medicare 
rules have not been 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 the service. Our physician reviewer 
found the enrollee has a history of myocardial infarction and percutaneous coronary intervention (PCI) with 
stent placement greater than two (2) years ago and has not had an evaluation for coronary artery disease (CAD) 
in the past 2 years. The enrollee is unable to exercise. The medical records provided meet the requirements 
listed in the LCD for Medicare coverage. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or 
quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when 
performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest 
reinjection (CPT code 78452).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown repair necessitated by restorative material failure 
(D2980) provided on November 5, 2021. 
 
You asked the Plan to pay for the crown repair. You say that the provider's office told you that this service 
would, or should, be covered by your insurance. The Plan denied your request. The Plan says this service is not 
a covered benefit under your dental plan. 
 
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, 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 crown 
repair necessitated by restorative material failure (D2980) provided on November 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on October 28, 2021. 
 
You asked the Plan to pay for the bitewing x-rays. You say that the bitewing x-rays you received on October 
28, 2021 were not the same ax the bitewing x-ray you received on September 8, 2021. The Plan denied your 
request. The Plan says this service exceeds the frequency limitation in your benefit plan. 
 
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, bitewing x-rays (either code D0270, 
D0272, D0273, D0274, or D0277) are limited to one procedure per plan year. The record shows that you 
received a single bitewing x-ray (D0270) on September 8, 2021 and your bitewing x-rays benefit has been 
exhausted. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided 
on October 28, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the services. We decided that the Plan does not have to pre-
approve the services for tooth #22.  
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan says that 
there is decay or infection that effects the outcome of this service. 
 
We decided that the Plan has to pre-approve the services for tooth #25.  
 
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 dental 
services when the services are medically necessary and reasonable.   
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 for a crown restoration for tooth #25. Our reviewer 
says that the services for tooth #25 are reasonable and necessary, as a review of the documentation indicates 
that tooth #25 has a large restoration with recurrent caries. A crown restoration appears reasonable and 
necessary to restore adequate function. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve the services for tooth #25.  
 
We also decided that the Plan does not have to pre-approve the services for tooth #22. 
 
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 dental 
services when the services are medically necessary and reasonable.  
 
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 for a crown restoration on tooth #22. Our reviewer 
says that the services for tooth #25 are not reasonable or necessary, as the radiograph for tooth #22 is 
inadequate, and an examination of the periapical area could not be done to determine if periapical pathology is 
present.  
 
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 services for tooth #22 have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the services for tooth #22. 
 
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 the rhythm ECG (93042) provided on November 28, 2021. 
 
You asked the Plan to pay for the rhythm ECG (93042). You say that a provider who prepares a separately 
identifiable interpretation which contributes to the diagnosis and treatment of the patient is entitled to payment. 
You say that the denied services should be reprocessed respective to CPT and CMS guidelines. The Plan 
denied your request. The Plan says this edit has a modifier indicator of 0, which indicates there are no 
modifiers allowed with this code pair.  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 93042 
is a column II code to column I code 99291 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for the rhythm ECG (93042) provided on November 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac risk assessment genetic screening testing provided to 
the enrollee on May 6, 2021. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare Part B covers cardiovascular disease screening tests when ordered by the physician 
who is treating the beneficiary for the purpose of early detection of cardiovascular disease in individuals 
without apparent signs or symptoms of cardiovascular disease. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. 
 Our physician reviewer found the clinical documentation does not support that the cardiac risk assessment 
genetic screening testing provided was medically reasonable and necessary to diagnose, treat, or otherwise 
manage 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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for cardiac risk assessment genetic screening testing provided to the enrollee on May 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint 
nerve(s) (CPT code 64635). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says your request is not medically necessary because your records show that 
there have been more than two (2) years since your previous RFA procedures and diagnostic procedures have 
not been repeated. 
 
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 you had your RFA more than two (2) years ago. The diagnostic blocks must be repeated first. Therefore, 
the request is deemed not medically reasonable and 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s) (CPT code 64635).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Velcade (CPT code J9041). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee has not tried and failed the preferred step therapy drug: generic 
bortezomib intravenous (J9044). The Plan states there is no indication the Plan's preferred generic form of the 
drug would likely be: less effective, and/or cause adverse effects for the enrollee. 
 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 the medication. Our physician reviewer 
found the enrollee has not tried and failed the required drug(s). There is no documentation provided indicating 
that the plans required drug(s) 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Velcade (CPT code J9041).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve the acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are medically 
necessary. The Plan denied your request. The Plan says that the services are not medically necessary. 
 
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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient admission are met in this case. Our 
physician reviewer found the enrollee presented with shortness of breath and was admitted on May 19, 2022, 
with congestive heart failure and non ST elevation myocardial infarction. Treatment included intravenous 
medications, cardiac monitoring and cardiology consultation. The record shows that at the time of inpatient 
admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including 
earlier emergency department 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 pre-approve the acute inpatient hospital care.  
 
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.