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

 
We decided that the Plan does not have to pay for an interim partial denture (D5821) provided on January 4, 
2022. 
 
You asked the Plan to pay for an interim partial denture. You say that you would like the Plan to pay for this. 
The Plan denied your request. The Plan says the rendered dental service is not a covered 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.  
 
 
 
 
 
  
Therefore, we decided that the Plan does not have to pay for an interim partial denture (D5821) provided on 
January 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 31, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing the claim payment denial. 
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 laboratory services 
provided on January 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (eg, MS, 
MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, qualitative or quantitative, 
each specimen (CPT code 83789-59) provided on August 7, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says modifier 59 is not appropriate as the records do not support a separate and distinct 
lab service. The Plan states the records do not support testing of a non-drug analyte as indicated in the code 
description. 
 
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 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 laboratory service. Our reviewer found documentation 
submitted was reviewed and does not meet criteria. The provider performed a urine drug screen with specimen 
validity testing. Providers performing validity testing on urine specimens utilized for drug testing shall not 
separately bill the validity testing. For example, if a laboratory performs a urinary pH, specific gravity, 
creatinine, nitrates, oxidants, or other tests to confirm that a urine specimen is not adulterated, this testing is not 
separately billed. In this case, service was unbundled. 
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for mass spectrometry and tandem mass spectrometry (eg, MS, MS/MS, MALDI, MS-
TOF, QTOF), non-drug analyte(s) not elsewhere specified, qualitative or quantitative, each specimen (CPT 
code 83789-59) provided on August 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine (90750) and administration (90472) 
provided on September 1, 2022. 
 
You asked the Plan to pay for the vaccine services. You say that you have received vaccines before. You say 
that they have never been denied. You also say that had you known it would not be covered, you would not 
have gotten it. The Plan denied your request. The Plan says the vaccine services are not covered under 
Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine services. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine 
services. Therefore, we decided that the Plan does not have to pay for the shingles vaccine (90750) and 
administration (90472) provided on September 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a neuroplasty and/or transposition; median nerve at 
carpal tunnel (64721), and synovectomy, extensor tendon sheath, wrist, single compartment (25118). 
 
You asked the Plan to pre-approve a neuroplasty and/or transposition; median nerve at carpal tunnel, and 
synovectomy, extensor tendon sheath, wrist, single compartment. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service is 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 a neuroplasty and/or transposition; 
median nerve at carpal tunnel, and synovectomy, extensor tendon sheath, wrist, single compartment. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the patient's prescribing physician did not provide sufficient clinical evidence to 
confirm compression of the left median nerve without left nerve testing results to view and to confirm this 
diagnosis of carpal tunnel syndrome on the left to support this request. 
 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 neuroplasty and/or transposition; median nerve at carpal tunnel, and 
synovectomy, extensor tendon sheath, wrist, single compartment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a neuroplasty and/or transposition; median nerve at carpal tunnel 
(64721), and synovectomy, extensor tendon sheath, wrist, single compartment (25118).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 64483 billed for date of service September 8, 2022. 
 
You asked the Plan to pay for the billed services. You say that the code was only billed once in 2022. The Plan 
denied your request. The Plan says that the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
The claim at issue shows that CPT code 64483 was billed with 1 unit of service. The case file does not include 
documentation that shows additional units of code 64483 was billed on the date of service at issue. Based on 
this information, we decided that Medicare rules for coverage of the billed services have been met. Therefore, 
we decided that the Plan has to pay for procedure code 64483 billed for date of service September 8, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic test provided on 
August 16, 2022. 
 
You asked the Plan to waive the copayment for outpatient diagnostic test. You say that you disagree with the 
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 $100 
copayment for outpatient diagnostic test/Medicare-covered radiological diagnostic services, not including X-
rays.  
 
You have been asked to pay a $100 copayment for outpatient diagnostic test. This item/service falls within the 
outpatient diagnostic test/Medicare-covered radiological diagnostic services, not including X-rays 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 outpatient diagnostic test provided on August 
16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service July 15, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the procedure is a covered benefit when 
performed at a contracted location. The Plan denied your request. The Plan says the billed place of service is 
inappropriate. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 71045 was billed with an outpatient place of service code. The enrollees claim 
information shows that the enrollee was receiving inpatient care at the time the services were rendered. Based 
on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 71045 billed for date of service July 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve an intracept procedure. You say that the service is medically necessary. The 
Plan denied your request. The Plan says this service 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 an intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this procedure in considered experimental and more research is needed to show 
safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an intracept procedure (64628, 64629).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study (95810). 
 
You asked the Plan to pre-approve a sleep study. You say that the service is needed to evaluate sleep 
disordered breathing. The Plan denied your request. The Plan says the requested service is 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 a sleep study. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee was diagnosed with obstructive sleep apnea (OSA) in 2014 and has been treated 
successfully with a continuous positive airway pressure (CPAP) device for years. However, the enrollee no 
longer has a CPAP device because of a recall. There has been no major change in health status or body 
weight. The enrollee has had several sleep studies since the diagnosis, and all have shown some degree of 
OSA, so the diagnosis is not in question. The enrollee had been compliant with the device prior to the recall.  
 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 sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sleep study (95810).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 8, 2022, to 
May 7, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. 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 reviewed 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 which is filed for the first date in 2022 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 April 8, 2022, to May 7, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings (D0274) provided on September 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. 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 August 5, 2022. 
Therefore, we decided that the Plan does not have to pay for bitewings (D0274) provided on September 7, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of a a bi-ventricular pacemaker (CRT-D). 
 
You asked the Plan to pre-approve a bi-ventricular pacemaker. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a bi-ventricular pacemaker is only covered for certain 
indications. 
 
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 bi-ventricular pacemaker. Our 
reviewer says that the documentation does not support that the requested services are medically reasonable or 
necessary. Our physician reviewer found the enrollee has cardiomyopathy with severe left ventricular 
dysfunction. The enrollee has an ejection fraction and left bundle branch block. The enrollee is noted to have 
NYHA functional Class I heart failure, not NYHA Class II or III. As such, guidelines would not support 
implant of a CRT-D. Therefore, there is insufficient documentation to support the medical necessity for 
implantation of a CRT-D in this enrollee's 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 a bi-ventricular pacemaker have not been met. Therefore, we decided that the 
Plan does not have to pre-approve implantation of a a bi-ventricular pacemaker (CRT-D).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for retainer crowns on tooth #9 and 11 (D6740) and a pontic on 
tooth #10 (D6245) provided on May 24, 2022. 
 
You asked the Plan to pay for the crowns and pontic. You say that you disagree with the denial of the dental 
services. The Plan denied your request. The Plan says retainer crowns (D6740) and pontics (D6245) are not 
covered by your dental 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 retainer 
crowns on tooth #9 and 11 (D6740) and a pontic on tooth #10 (D6245) provided on May 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) and accessory 
provided on April 12, 2022. 
 
You asked the Plan to pay for the PCD and accessory. The Plan denied your request. The Plan says this is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a PCD coded as E0675 is used in the treatment of 
peripheral arterial disease. Claims for E0675 will be denied as not reasonable and necessary.  
 
We looked at the file and Medicare rules. Per LCD L33829, the requested PCD (E0675) is not medically 
reasonable and necessary. As the PCD is not covered, the accessory (E0673) is also not covered. Based on this information, we decided that Medicare rules for coverage of the PCD and accessory have not been met. 
Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (PCD) and 
accessory provided on April 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliances (E0673) provided June 8, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliances. You say that the equipment was 
prescribed by the doctor and was issued to the enrollee for use during their surgery. The Plan denied your 
request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein 
thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) and segmental pneumatic appliances (E0673) provided June 
8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pneumatic compression device (E0652) and 
segmental pneumatic appliances (E0656, E0667) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the pneumatic compression device and appliances. You say that the enrollee 
has tried a basic pump one time and it failed as it does not address the trunk. The Plan denied your request. The 
Plan says enrollees must receive their medical services from an in-network provider with the exception being 
urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization 
before services being rendered. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the pneumatic compression device (E0652) and segmental pneumatic appliances (E0656, E0667) to be 
provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a metal crown (D2751) for tooth #14. 
 
You asked the Plan to pre-approve the dental service. You say that you are in extreme pain and the dentist 
cannot do a filling on the tooth. The Plan denied your request. The Plan says that the x-rays provided do not 
show a crown is needed to fix the enrollee's tooth. 
 
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 dental 
service 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 dental service. Our reviewer says 
that the crown for tooth #14 is medically necessary. Our physician reviewer found that the documentation 
indicates that tooth #14 has a large restoration with recurrent distal caries. It is medically reasonable and 
necessary to place a crown restoration to provide adequate masticatory function. 
 
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 dental service have been met. Therefore, we decided that the Plan has to 
pre-approve a metal crown (D2751) for tooth #14.  
 
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.