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

 
We decided that the Plan does not have to pay for a resin-based composite (D2394) provided by an out-of-
network provider on January 14, 2022. 
 
You asked the Plan to pay for a resin-based composite. You say that this was an emergency. You say that you 
needed these services done. The Plan denied your request. The Plan says this claim has been processed 
correctly. 
 
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 resin-based 
composite when the services are provided by a participating provider. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a resin-based composite have not been met. Therefore, we decided that the Plan does not have to 
pay for a resin-based composite (D2394) provided by an out-of-network provider on January 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 6, 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 August 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty (22513, 22515) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that under Medicare guidelines the request is not 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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee's compression fractures do not meet criteria for 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty (22513, 22515) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) machine 
purchased on October 11, 2021. 
 
You asked the Plan to pay for these services. You say that you were assured the item would be covered. The 
Plan denied your request. The Plan says the provider is not Medicare-certified. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are 
furnished by a provider or supplier enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. The file shows that the provider was not Medicare-certified. 
Therefore, we decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) 
machine purchased on October 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary and mandibular denture (D5110 
and D5120) provided by a participating provider. 
 
You asked the Plan to pre-approve a complete maxillary and mandibular denture. You say that you would like 
the Plan to pay for this. The Plan denied your request. The Plan says this claim is being processed correctly. 
 
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 up to a $2,000 
maximum allowance benefit for covered dental services. 
 
We looked at the file and Medicare rules. The total amount that is being requested is $3,194. The Plan will pay 
$2,000, leaving a remaining balance of $1,194. Based on this information, we decided that the Plan's rules for 
coverage of a complete maxillary and mandibular denture have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a complete maxillary and mandibular denture (D5110 and D5120) provided 
by a participating provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on October 4, 2021, to October 25, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for physical therapy. You say that these services were medically necessary. The Plan 
denied your request. The Plan says prior authorization was not obtained by the member's primary care 
physician. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to 
pay for these items/services. Therefore, we decided that the Plan does not have to pay for physical therapy 
provided on October 4, 2021, to October 25, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 2, 2021 by a 
non-contracted provider. 
 
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 rendered by a non-contracted provider without prior authorization. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on September 2, 
2021 by a non-contracted provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve alveoloplasty not in conjunction with extractions 
(D7321) and inhalation of nitrous oxide (D9230). 
 
You asked the Plan to pre-approve dental services. You say that these services are necessary. The Plan denied 
your request. The Plan says these services are not covered by 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. Alveoloplasty not in conjunction with extractions is not a 
listed/covered service. Inhalation of nitrous oxide is covered only when deemed necessary with a covered 
procedure. Because the alveoloplasty in this case is not covered, the nitrous is not covered either. Therefore, we 
decided that the Plan does not have to pre-approve alveoloplasty not in conjunction with extractions (D7321) 
and inhalation of nitrous oxide (D9230).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Dual-energy X-ray absorptiometry (DXA), bone density 
study provided on December 21, 2021. 
 
You asked the Plan to pay for a Dual-energy X-ray absorptiometry (DXA), bone density study. The Plan 
denied your request. The Plan says with the information we have, we cannot determine how the member came 
to the servicing provider, or whether the services are medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a Dual-energy X-ray absorptiometry 
(DXA), bone density study provided on December 21, 2021 have been met. Therefore, we decided that the Plan 
does not have to pay for a Dual-energy X-ray absorptiometry (DXA), bone density study provided on 
December 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for WoundEx Flow Amniotic Fluid injections for the enrollee. 
 
You asked the Plan to pay for the injections. You say that Medicare covers this service. The Plan denied your 
request. The Plan says WoundEx Flow Amniotic Fluid injections for the treatment of osteoarthritis of the hand 
are not proven in peer-reviewed medical 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 pay for the injections. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the clinical value and effectiveness of WoundEx Flow amniotic fluid injections in the setting of 
osteoarthritis of the hand has not been demonstrated in the peer-reviewed literature. The Medicare criteria for 
reasonable and necessary are not met as it has not been shown to be safe and effective in long term studies and there is a lack of evidence to support that joint injection of human amniotic fluid is considered experimental, 
investigation, and or unproven for all indications, including the treatment of osteoarthritis. WoundEx Flow 
amniotic fluid injections are considered investigational and not medically necessary for the treatment of 
osteoarthritis of the right hand. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pay for WoundEx Flow Amniotic Fluid injections for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would prefer to admit to an IRF because you 
were independent before your hospitalization and want to return to being independent. The Plan denied your 
request. The Plan says based on Medicare guidelines, the requested IRF services do not meet the requirements 
for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 IRF care.  Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on 
Medicare guidelines. Our physician reviewer found that the complexity of your nursing, medical and 
rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While 
the documentation does support a need for physical and/or occupational therapy, there is no documented need 
for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will 
be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (G0483) provided on December 1, 2021. 
 
You asked the Plan to pay for code G0483. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the medical records do not support the billing of code 
G0483. 
 
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 Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the record does not contain 
evidence that definitive testing on 22 or more drug classes was performed. Therefore, we decided that the Plan 
does not have to pay for the drug testing (G0483) provided on December 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on May 4, 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 May 4, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve genetic testing (0012M) provided February 18, 2021. 
 
You asked the Plan to pre-approve the genetic testing. You say that this service was medically necessary. The 
Plan denied your request. The Plan says that the case was forwarded to the IRE because the plan was able to 
make a coverage determination in 60 days. 
 
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 documentation provided by the plan does not articulate why this service was 
denied. Per Local Coverage Article: Biomarkers for Oncology (A58529), this service was eligible for Medicare 
coverage as of June 1, 2020. Therefore, we decided that the Plan has to pre-approve genetic testing (0012M) 
provided February 18, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain crown (D2740) for the enrollee. 
 
You asked the Plan to pre-approve the crown. You say that this is medically necessary. The Plan denied your 
request. The Plan says the x-rays do not show more than 50% bone loss, which is a clinical requirement for the 
crown 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. The Plan covers the crown 
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 to pre-approve the crown. Our reviewer says that the 
requested crown is not medically reasonable or necessary. Our physician reviewer found the request has been 
made for a crown on  tooth #4. The tooth has an existing two surface restoration that the provider noted to be 
failing along with new mesial caries. About 45% of the tooth would be involved if there were restoration to the 
tooth  replacing the existing amalgam and incorporating the mesial aspect for the new carious lesion. The x-ray 
reveals a periodontal defect on the distal of #4 which has caused about 60% attachment/bone loss in that area. 
Given the situation as presented, the extent of the existing restoration and ability to replace and restore with 
conventional restorations as well as the local severe periodontal defect, the criteria for crowns has not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a porcelain crown (D2740) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified preventative procedure (D1999), provided by 
a participating provider on January 5, 2022. 
 
You asked the Plan to pay for an unspecified preventative procedure. You say that you feel like you are being 
ripped off. The Plan denied your request. The Plan says this claim has been processed correctly. 
 
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 an 
unspecified preventative procedure (D1999), provided by a participating provider on January 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve EpiCord skin substitute for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that the records provided support the need for EpiCord 
skin substitute. The Plan denied your request. The Plan says EpiCord skin substitute is considered experimental 
and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation does not support that EpiCord skin substitute is medically reasonable and necessary 
for the enrollee in this case. It has not been shown that this skin substitute is an accepted standard of medical 
practice that improve healing rates in the treatment of the enrollee's condition. Additionally, it has not been 
demonstrated that the EpiCord skin substitute meets, but does not exceed, the enrollee's medical need, and is at 
least as beneficial as an existing and available medically appropriate alternative. 
 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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve EpiCord skin substitute for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2391), provided by a participating 
provider on November 3, 2021. 
 
You asked the Plan to pay for a resin-based composite. You say that you would like this to be processed with 
your 2022 benefits. The Plan denied your request. The Plan says this claim has been processed correctly. 
 
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. The Plan covers covered 
dental benefits up to a $1,000 benefit maximum allowance amount. 
 
We looked at the file and Medicare rules. Evidence was provided to show that the $1,000 benefit maximum 
allowance has already been met and exhausted. Based on this information, we decided that the Plan's rules 
for coverage of a resin-based composite have not been met. Therefore, we decided that the Plan does not have to 
pay for a resin-based composite (D2391), provided by an out-of-network provider on November 3, 2021.