Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power mobility device and accessories (K0860, 1028, 
E1002, E2608, E2310, E2363, E0955, E0955 K0040 and E1028). 
 
You asked the Plan to pre-approve a PMD and accessories. You say that the requested items are medically 
necessary. The Plan denied your request. The Plan says you do not meet criteria for the PMD. Review of the 
records provided demonstrates you have sufficient upper extremity strength to use a manual wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a PMD and accessories. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the documentation indicates you 
have a mobility deficit that impairs MRADLs in the home. The documentation is not clear why you are unable 
to use a manual wheelchair given full ROM, normal tone, and strength in the upper extremities. The 
documentation states gross and fine UE motor control is functional. Pain is noted only at end range. You are 
currently able to use a cane and the provider is not clear on baseline or why a wheelchair is not indicated. 
Furthermore, the treating medical provider does not perform a clear upper extremity evaluation with detailed 
neuromuscular and musculoskeletal findings. The wheelchair evaluation states you have functional upper 
extremity control. The document is not clear that you have trialed a manual wheelchair and is unable to use it 
effectively given your strength and range of motion. 
 
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 PMD and accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power mobility device and accessories (K0860, 1028, E1002, E2608, E2310, 
E2363, E0955, E0955 K0040 and E1028).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildups (D2750 x2), endodontic therapy (D3320), and 
pulp vitality tests (D0460) provided from March 22, 2022, through April 8, 2022. 
 
You asked the Plan to pay for core buildups, endodontic therapy, and pulp vitality tests. You say that you were 
not aware that the provider was out-of-network. The Plan denied your request. The Plan says the services at 
issue 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 pay for core 
buildups (D2750 x2), endodontic therapy (D3320), and pulp vitality tests (D0460) provided from March 22, 
2022, through April 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation 
(D7953), two core buildups, including any pins when required (D2950 x2), and a retainer crown (D6740). 
 
You asked the Plan to pre-approve a bone replacement graft, core buildups, and retainer crown. You say that x-
rays and photos from the enrollee's comprehensive examination, as well as preparation, very clearly show the 
necessity of the restorations. The Plan denied your request. The Plan says a bone replacement graft is not a 
covered benefit. The Plan also says that your limitations for core buildups and retainer crown have been met for 
the calendar year 2022. 
 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, bone replacement graft for ridge 
preservation (D7953) is not among those covered under this benefit. The record also shows your benefits for 
the remaining core buildups, including any pins when required (D2950), and retainer crowns (D6740) were 
approved for coverage on September 2, 2022, and have been exhausted. Therefore, we decided that the Plan 
does not have to pre-approve a bone replacement graft for ridge preservation (D7953), two core buildups, 
including any pins when required (D2950 x2), and a retainer crown (D6740).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the power wheelchair provided on February 9, 2022. 
 
You asked the Plan to pay for the power wheelchair. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says that precertification/authorization is absent. 
 
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. Review of the file shows that the Plan has denied this claim due to the 
precertification/authorization being absent. However, the documentation includes an authorization notice for 
dates July 7, 2021, to July 7, 2022 for the item rendered. No other explanation of this denial is provided by the 
Plan. Therefore, we decided that the Plan has to pay for the power wheelchair provided on February 9, 2022.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81479 provided on March 3, 
2022. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 81479 is not supported in the medical record. Specifically, the documentation shows 
that the specimen was collected on February 10, 2022. This is not the date billed. This claim is not payable as 
billed. Based on this information, we decided that Medicare rules for coverage of the laboratory services have 
not been met. 
 
 
 
 
  
 Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81479 provided on 
March 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC panel provided to the enrollee on May 
5, 2022. 
 
You asked the Plan to pay for the DecisionDx-SCC panel. You say that this claim should be reprocessed and 
paid. The Plan denied your request. The Plan says that further investigation is needed to establish such testing 
as the standard of care in managing cutaneous squamous cell carcinoma. 
 
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. The Arizona LCD was used as the testing was 
performed in Arizona. 
 We looked at the file and Medicare rules. We found that the DecisionDx-SCC panel is listed as noncovered in 
the DEX database. Based on this information, we find that the Medicare coverage rules for the DecisionDx-
SCC panel have not been met. Therefore, we decided that the Plan does not have to pay for the DecisionDx-
SCC panel provided to the enrollee on May 5, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 74019-26 billed for date of service March 7, 2022. 
 
You asked the Plan to pay for code 74019-26. You say that this claim was denied in error. The Plan denied 
your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on April 1, 2022. Comparison of the two claims shows these are exact duplicates. There 
is no evidence presented to support that the billed items/services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for code 74019-26 have not been met. Therefore, we 
decided that the Plan does not have to pay for code 74019-26 billed for date of service March 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prescription custom fabricated foot insert, each, 
removable (L3020) purchased February 24, 2022. 
 
You asked the Plan to pay for foot orthotics. You say that you have Tendonitis and PES Planus of both feet so 
the orthotic inserts are medically necessary. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for the prescription custom fabricated foot 
insert, each, removable (L3020) purchased February 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient office visit (99213) 
ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation (92316) 
provided April 19, 2022. 
 
You asked the Plan to waive the copayment for the vision services. You say that this visit was a follow up visit 
from your cataract surgery you had on April 18, 2022 and you are not usually charged for follow up visits. The 
Plan denied your request. The Plan says this claim was processed with the correct cost share applied per the 
Evidence of Coverage 
 
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 $45 
copay for specialist exams.  
 You have been asked to pay $45 copay for the vision services. The vision services fall within the Vision care 
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. 
Therefore, we decided that the Plan does not have to waive the copayment for the outpatient office visit 
(99213) ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation 
(92316) provided April 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services on June 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that you feel misguided and that the office was 
dishonest about the situation. The Plan denied your request. The Plan says the dental services were received 
from an out-of-network provider and are not covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services on June 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service April 25, 
2022. 
 
You asked the Plan to pay for procedure code 99100. The Plan denied your request. The Plan says procedure 
code 99100 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service April 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulation (tens) 
device, four or more leads, for multiple nerve stimulation (E0730). 
 
You asked the Plan to pre-approve a TENS device. You say that you disagree with the denial and have 
submitted medical records for review. The Plan denied your request. The Plan says outreach to the referring 
provider confirmed he did not write the order for the denied item. The documentation submitted did not include 
a valid physician order. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order.  
 
 
 
The record does not contain a valid physician order. The record shows that outreach was made to the referring 
provider and the provider states he did not write the order for the denied item. Therefore, we decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulation (tens) device, four or more 
leads, for multiple nerve stimulation (E0730).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 9, 2021, billed with 
codes 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81295, 81298, 81301, 81311, 81317, 81321, and 
81194. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
is supported in the medical record. The Plan denied your request. The Plan says this claim was not billed in 
accordance with Medicare rules. 
 
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 
April 9, 2021, billed with codes 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81295, 81298, 81301, 
81311, 81317, 81321, and 81194.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 75571 billed for date of service March 29, 
2022. 
 
You asked the Plan to pay for procedure code 75571. The Plan denied your request. The Plan says payment for 
code 75571 is bundled into payment for code 71250.  
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 75571 
is a column II code to column I code 71250. 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 75571 billed for date of service March 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code G0406-95 billed for date of service January 10, 2022. 
 
You asked the Plan to pay for code G0406-95. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says this code is not supported in the medical record. 
 
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 G0406-95 is Follow-up inpatient consultation, limited, 
physicians typically spend 15 minutes communicating with the patient via telehealth. 
 
We find that CPT code G0406-95 is not supported in the medical record. Specifically this code is a timed code, 
meaning that the number of minutes spent on this service must be documented in the medical record.  The 
medical record does not document the amount of time spent on this telehealth service. Based on this 
information, we decided that Medicare rules for coverage of code G0406-95 have not been met. Therefore, we 
decided that the Plan does not have to pay for code G0406-95 billed for date of service January 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 38510 billed for date of service May 13, 
2022. 
 
You asked the Plan to pay for procedure code 38510. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 38510 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 38510 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 38510 billed for date of service May 13, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasonic guidance provided on March 17, 2022. 
 
You asked the Plan to pay for the services provided. You say that the procedure was used to complete the 
primary procedure. The Plan denied your request. The Plan says this procedure is considered inclusive to 
another code. 
 
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 76942 is ultrasonic guidance for needle placement (e.g., 
biopsy, aspiration, injection, localization device), imaging supervision and interpretation.  We find that CPT code 76942 is not supported in the medical record. The medical records do not indicate the 
imaging services were an unusual non-overlapping service. Based on this information, we decided that 
Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan 
does not have to pay for the ultrasonic guidance provided on March 17, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the services requested are medically necessary. The 
Plan denied your request. The Plan says the criteria for admission to SNF have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there are no identifiable skilled nursing service needs or skilled therapy service 
needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan has to pay for the FoundationOne CDx testing provided on February 1, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says that this is not medically 
necessary 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 considered medically reasonable and necessary in this case. Our physician reviewer 
found that FoundationOne CDx is an FDA-approved comprehensive genomic profiling (CGP) test for all solid 
tumors that incorporates multiple companion diagnostics.  FoundationOne CDx detects tumor BRCA1 and 
BRCA2 mutations including both germline (inherited) and somatic (acquired) mutations. The enrollee's 
diagnosis is H0589 "Other disorders of orbit". The testing at issue in this case is 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 testing have been met. Therefore, we decided that the Plan has to pay for the 
FoundationOne CDx testing provided on February 1, 2022.  
 
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.