Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 29, 2022, billed with 
codes 81225, 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81306, 81328, 81355, 81401, 0031U, 0032U 
and 0033U. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
August 29, 2022, billed with codes 81225, 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81306, 81328, 
81355, 81401, 0031U, 0032U and 0033U.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve SSBCI benefits. 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you believe you are eligible for the SSBCI 
benefits. The Plan denied your request. The Plan says that you do not meet all the criteria to be eligible for 
SSBCI benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the plan did not send us medical records. You say that you should 
be eligible for SSBCI benefits due to your health issues. Without medical records, we cannot determine 
whether or not you are eligible for the benefits. Therefore, the Plan has not shown that their decision to deny 
the benefit is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pre-
approve the SSBCI benefits. 
 
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 a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that this item is medically necessary. The Plan 
denied your request. The Plan says there is no compelling argument as to why a Bilevel Positive Airway 
Pressure (BiPAP) with Average Volume-Assured Pressure Support (AVAPS) cannot be used instead of a 
ventilator. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 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 home ventilator. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found this patient has a history of 
chronic obstructive pulmonary disease, obstructive sleep apnea, and obesity hypoventilation syndrome.  A 
recent arterial blood gas during an exacerbation was consistent with mild chronic hypercarbic respiratory 
failure.  Pulmonary function tests show an FEV1 of 55% of predicted with a normal FEV1/FVC and normal 
total lung capacity. This patient may benefit from BiPAP with AVAPS during sleep.  Medicare does not cover 
a home ventilator for the treatment of obesity hypoventilation syndrome, or when used at settings that can be 
provided with BiPAP.  
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Kerecis Omega 3 (fish skin developed for the 
management of chronic wounds) (Q4158), Allopatch (skin substitute) (Q4128), Amnioband (skin substitute) 
(Q4151), and Skin Grafts (application of skin substitute) (15275, 15271). 
 
You asked the Plan to pre-approve the Kerecis Omega 3, Allopatch, and Skin Grafts. You say that the services 
are medically necessary. The Plan denied your request. The Plan says the services are 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 the Kerecis Omega 3, Allopatch, and 
Skin Grafts. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is not enough information to make an informed 
decision.  
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 Kerecis Omega 3, Allopatch, and Skin Grafts have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the Kerecis Omega 3 (fish skin developed for the 
management of chronic wounds) (Q4158), Allopatch (skin substitute) (Q4128), Amnioband (skin substitute) 
(Q4151), and Skin Grafts (application of skin substitute) (15275, 15271).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic image (D0210) and the oral 
photographic images (D0350) provided on December 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you just enrolled into the Plan and the services 
were denied in error. The Plan denied your request. The Plan says your benefit for the intraoral radiographic 
image has already been exhausted. Also, the denial of payment for the oral photographic images is correct 
because they are not covered by the 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, certain limitations apply. The record 
shows the Plan paid for a panoramic radiographic image on December 6, 2022; therefore, your benefit for the 
intraoral radiographic image was exhausted on the date of service of December 6, 2022. The oral photographic 
image is not covered under the Plans dental benefit . Therefore, we decided that the Plan does not have to pay 
for the intraoral radiographic image (D0210) and the oral photographic images (D0350) provided on December 
6, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing services provided to the enrollee on March 15, 2022.
You asked the Plan to pay for the laboratory testing services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the required unique identifier.
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the coverage status is listed in the DEXTM Diagnostics Exchange. We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory testing services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory testing services provided to the enrollee on March 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) and a core buildup (D2950) provided on 
November 8, 2022. 
 
You asked the Plan to pay for a crown and core buildup. You say that this should be covered. The Plan denied 
your request. The Plan says these are not covered services. 
 
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 a crown 
(D2740) and a core buildup (D2950) provided on November 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost share for the dental services provided from July 31,
2020, to June 1, 2022.
You asked the Plan to reduce the cost share for the dental services. You say that you were overcharged for the
dental services. The Plan denied your request. The Plan says that the dental claims were 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.
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record
shows your benefit for the limited oral evaluation (D0140) provided on April 9, 2021, the periodic
oral evaluation (D0120) provided on July 6, 2021, the periapical x-ray (D0220) provided on April 8, 2022, the
filling provided on February 22, 2022, and the periapical x-ray provided on June 1, 2022 was exhausted on
their dates of service. The periapical x-rays (D0220, D0230) were not covered under your dental benefit on
dates of service July 31, 2020, and August 4, 2020. The fillings provided on July 31, 2020, August 4, 2020,
May 11, 2021, and February 8, 2022, paid with the appropriate coinsurance. The crowns provided on
September 2, 2020, and September 25, 2020, paid with the appropriate coinsurance Therefore, we decided that
the Plan does not have to reduce the cost share for the dental services provided from July 31, 2020, to June 1,
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical removal of erupted tooth requiring removal of bone 
(D7210) provided on November 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service October 7, 2022. 
Therefore, we decided that the Plan does not have to pay for surgical removal of erupted tooth requiring 
removal of bone (D7210) provided on November 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463) provided on October 13, 2020.
You asked the Plan to pay for the hospital outpatient clinic visit. You say that this should be covered. The Plan denied your request. The Plan says that the claim was filed untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the hospital outpatient clinic visit was not filed until June 2, 2022.
This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463) provided on October 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ultrasound guided radiation therapy (G6001). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says there is not enough evidence that this type of radiation therapy guidance is needed or 
effective for your skin cancer. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found billing for daily image-guided radiation therapy (IGRT) which would not be furnished in 
accordance with accepted standards of medical practice. 
 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 the ultrasound guided radiation therapy (G6001).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure. 
 
You asked the Plan to pre-approve the intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says this 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 the intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered experimental. 
 
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 intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - complete series of radiographic images (D0210) 
provided on October 11, 2022. 
 
You asked the Plan to pay for intraoral - complete series of radiographic images. You say that this should be 
covered. The Plan denied your request. The Plan says this is not a covered service. 
 
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 intraoral - 
complete series of radiographic images (D0210) provided on October 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for restorative services (D2150, D2160) provided on December 
1, 2022. 
 
You asked the Plan to pay for the dental services. You say that these should be covered. The Plan denied your 
request. The Plan says you have met your benefit maximum allowance of $500 per calendar year during these 
services. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service December 1, 2022. Therefore, we decided that the Plan does not have to pay for restorative services (D2150, D2160) provided on 
December 1, 2022.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve deep gum and root cleaning, all four quadrants (D4341). We 
decided that the Plan does not have to pre-approve white glass with high gold content crown (D2750) Tooth 
#19 and surgical bone reshaping on 4+ teeth, all four quadrants (D4260). 
 
You asked the Plan to pre-approve deep gum and root cleaning, all four quadrants (D4341) white glass with 
high gold content crown (D2750) Tooth #19, and surgical bone reshaping on 4+ teeth, all four quadrants 
(D4260). You say that the requested services are medically necessary. The Plan says that white glass with high 
gold content crown (D2750) Tooth #19 and deep gum and root cleaning, all four quadrants (D4341) do not 
meet criteria. Surgical bone reshaping on 4+ teeth, all four quadrant (D4260) is not a covered benefit. 
 
We decided that the Plan has to pre-approve deep gum and root cleaning, all four quadrants (D4341).  
 
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. 
 
Our doctor found that a review of the documentation indicates that deep gum and root cleaning, all four 
quadrants (D4341) meets criteria, therefore is medically necessary. 
  
We also decided that the Plan does not have to pre-approve white glass with high gold content crown 
(D2750) Tooth #19. 
 
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. 
 
Our doctor found that a review of the documentation indicates white glass with high gold content crown 
(D2750) Tooth #19 does not meet criteria; therefore, is not medical necessary. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D4260 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve surgical 
bone reshaping on 4+ teeth, all four quadrants (D4260). 
 
 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 pre-approve a Technetium Tc-99m tetrofosmin, diagnostic, per study 
dose (A9502) and myocardial perfusion imaging, tomographic (78452). 
 
You asked the Plan to pre-approve myocardial perfusion imaging. You say that the enrollee is having chest and 
leg pain and is unable to exercise. The Plan denied your request. The Plan says the request is not medically 
necessary because the records do not show that the enrollee has any of the covered indications for cardiac 
imaging as part of your stress testing. 
 
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 myocardial perfusion imaging. 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 had no cardiac symptoms and is undergoing 
echocardiography. There is no documentation that the ECG shows an uninterpretable pattern. There is no 
evidence provided that would support the need for radionuclide stress testing at this time. In summary, there is 
insufficient documentation to support the medical necessity for the requested cardiac stress testing in this 
enrollee's clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of myocardial perfusion imaging have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Technetium Tc-99m tetrofosmin, diagnostic, per study dose (A9502) 
and myocardial perfusion imaging, tomographic (78452).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 14, 2022, 
to October 13, 2022. 
 
You asked the Plan to pay for the home health services as billed. The Plan denied your request. The Plan says 
the claim has not been billed with the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We looked at the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA as required. Based on this information, we find that the Medicare rules for 
payment of the claim at issue have not been met. Therefore, we decided that the Plan does not have to pay for 
the home health services provided from September 14, 2022, to October 13, 2022.