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

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
(87798, 87186, 87563, 87640, 87799, 87482, 87500, 87801, 87651) provided on January 10, 2022. 
 
You asked the Plan to pay for the urine PCR panel testing. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets. 
 
We looked at the file and Medicare rules. This was a 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 urine PCR panel 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing (87798, 87186, 87563, 87640, 87799, 87482, 87500, 87801, 87651) 
provided on January 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) 
 
You asked the Plan to pre-approve a CGM. You say that you would like approval for a CGM. The Plan denied 
your request. The Plan says a CGM has been correctly denied. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a continuous glucose monitor (CGM)
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a custom fabricated abutment, abutment supported 
porcelain/ceramic crown, and pontic (D6057, D6245, D6058). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says that your $5,000 dental benefit maximum 
allowance for the requested item or service has already been exhausted. 
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pre-approve a custom fabricated abutment, abutment 
supported porcelain/ceramic crown, and pontic (D6057, D6245, D6058).  
 
  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 a chiropractic visit provided on August 24, 2022. 
 
You asked the Plan to pay for a chiropractic visit. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a chiropractic visit 
provided on August 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on February 25, 
2022. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, the provider billed the durable medical equipment with a 
GY modifier, which indicates the services are not covered under Medicare. However, the enrollee is not responsible for these charges. Therefore, we decided that the Plan does not have to pay for the durable medical 
equipment provided on February 25, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve infrared therapy with an out-of-network psychologist. 
 
You asked the Plan to pre-approve infrared therapy with an out-of-network psychologist. You say that you 
were recently hit by a car and were concerned with having a concussion. The Plan denied your request. The 
Plan says the infrared therapy is not a covered benefit. The Plan also says that therapy services are available to 
you and can be received from providers who are in-network. 
 
The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to conclude the use of 
infrared therapy devices and any related accessories is not reasonable and necessary under section 
1862(a)(1)(A) of the Social Security Act (the Act).  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of infrared therapy with an out-of-network psychologist have not been met. Therefore, we decided 
that the Plan does not have to pre-approve infrared therapy with an out-of-network psychologist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral-complete series of radiographic images (D0210) 
provided on November 28, 2022. 
 
You asked the Plan to pay for this dental service. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the service provided 
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 service provided was exhausted on date of service August 20, 2019. Specifically, the 
Plan contract says that one complete series of radiographic images or panoramic x-ray is covered every five 
calendar years. You previously received a panoramic radiographic image on August 20, 2019, which was paid 
for by the Plan. Therefore, you have exhausted the allowable benefit for this service.  Therefore, we decided that the Plan does not have to pay for the intraoral-complete series of radiographic 
images (D0210) provided on November 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the application of fluoride (D1206), core buildup 
(D2950), crowns (D2740), pulp caps (D3120), and periodontal scaling and root planing (D4341) for tooth #18 
and #31. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied dental 
services. The Plan denied your request. The Plan says the denial of authorization for these services is correct, 
because the application of fluoride, core buildup, crowns, pulp caps, and periodontal scaling and root planing 
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, 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 the 
application of fluoride (D1206), core buildup (D2950), crowns (D2740), pulp caps (D3120), and periodontal 
scaling and root planing (D4341) for tooth #18 and #31.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140). 
 
You asked the Plan to pay for the dental services. You say that the frequency provision should not be applied as 
it was for the one tooth so it should be considered the one event. The Plan denied your request. The Plan says 
your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. This benefit includes the 
requested limited oral evaluation - problem focused (D0140) but is limited to one procedure per plan year. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested D0140 was exhausted on date of service August 10, 2022. The Plan 
received the claim for August 10, 2022, before it received the claim for July 26, 2022, therefore one procedure 
per plan year was paid. Therefore, we decided that the Plan does not have to pay for limited oral evaluation - 
problem focused (D0140).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation (D4921), and an interim crown 
(D2799). 
 
You asked the Plan to pre-approve gingival irrigation, and an interim crown. You say that you would like pre-
approval for these services. The Plan denied your request. The Plan says the requested dental services are not 
covered benefits. 
 
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 
gingival irrigation (D4921), and an interim crown (D2799).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network diagnostic bone (DXA) scan 
provided on December 14, 2022. 
 
You asked the Plan to waive the copayment for an in-network diagnostic bone (DXA) scan. You say that your 
paperwork clearly says this is a $0 copayment. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for other outpatient diagnostic tests. 
 
You have been asked to pay a $20 copayment for an in-network diagnostic bone (DXA) scan. This item/service 
falls within the other outpatient diagnostic tests benefit category. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. This was a diagnostic test, therefore, the $20 copayment was 
applied. Therefore, we decided that the Plan does not have to waive the copayment for an in-network 
diagnostic bone (DXA) scan provided on December 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (E2103) 
 
You asked the Plan to pre-approve the CGM. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as you do not meet the 
clinical requirements to be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
   We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (E2103)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to preapprove a continuous glucose monitor (CGM) (A4239). 
 
You asked the Plan to preapprove the CGM. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as the enrollee does not 
meet the clinical requirements to be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to preapprove a continuous glucose monitor (CGM) (A4239).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the gel-one injection and the joint injection 
provided on September 28, 2022. 
 
You asked the Plan to waive the copayment for the gel-one injection and the joint injection. You say that you 
do not agree with the cost sharing applied to these services. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance of the total cost for all other Medicare-covered Part B drugs, and a $305 copayment for Medicare-
covered surgical services at an outpatient hospital. 
 
 You have been asked to pay a cost share of $195.24 for the gel-one injection ($976.18 total cost x .20 = 
$195.24). This item/service falls within the Medicare Part B prescription drugs benefit category. You have also 
been asked to pay a $40 copayment for the joint injection because the Plan is only holding you responsible for 
this amount, which is less than $305. This item/service falls within the outpatient surgery, including services 
provided at hospital outpatient facilities and ambulatory surgical centers benefit category.  
 
You have been asked to pay a total cost share of $235.24 for the gel-one injection and the joint injection. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the gel-one injection and the joint injection provided on 
September 28, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 20, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 20, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation (D4921) and gum medication 
(D4381). 
 
You asked the Plan to pre-approve the dental services. You say that you would like pre-authorization for these 
services. The Plan denied your request. The Plan says the denied dental services are not covered benefits. 
 
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 
gingival irrigation (D4921) and gum medication (D4381).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation, intraoral x-ray, and cleaning 
(D0120, D0210, D1110) provided on April 19, 2022, to October 26, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the charges. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. 
 
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. 
 
 
  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for a periodic oral evaluation, intraoral x-ray, 
and cleaning (D0120, D0210, D1110) provided on April 19, 2022, to October 26, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95907 and 95937 provided to the enrollee 
on October 13, 2022. 
 
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 the denied codes are not supported by the medical records submitted. 
 
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 the denied codes is: 
 
CPT 95907: 
 
Nerve conduction studies; 1-2 studies  
CPT 95937: 
 
Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the records do not support the use of 
CPT 95907 in this case. The intraoperative neurophysiology report cites MEPs (motor evoked potentials) that 
were obtained in bilateral abductor pollicis brevis (APB), transversus abdominis (TA), and flexor hallucis 
brevis (FHB) remained stable throughout the procedure. This supports that more than 1-2 studies were 
rendered. 
 
Additionally, our reviewer found that the intraoperative neurophysiology report cites train of four was utilized 
throughout the procedure to assess the neuromuscular junction for level of paralysis due to administration of 
relaxant by anesthesia. Train of four monitoring is a bundled service and cannot be separately reported. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 95907 and 95937 provided to the enrollee on October 13, 2022.