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

 
We decided that the Plan does not have to pay for dental services provided on December 2, 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 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 provided on December 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient hospital care. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that acute inpatient hospital care is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the request for acute inpatient 
hospital care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. 
  
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient admission are met in this case. Our 
physician reviewer found that detailed documentation is not evident in the case record regarding a significant 
past and/or current medical history that would place the enrollee at increased risk for peri-surgical 
complications requiring an inpatient stay. The record does not show that at the time of inpatient admission, the admitting physician would reasonably expect that the enrollee's necessary hospital care (including earlier ED 
and/or observation care) would span two midnights. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for acute inpatient hospital care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mammography provided on January 27, 2023. 
 
You asked the Plan to pay for mammography. You say that you are requesting reconsideration. 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 mammography provided 
on January 27, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20939-RT and 20937 billed for October 6, 
2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 20939-RT and 20937 are not supported. 
 
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 20939 is bone marrow aspiration for bone grafting, spine 
surgery only, through separate skin or fascial incision (List separately in addition to code for primary 
procedure). The definition of code 20937 is autograft for spine surgery only (includes harvesting the graft); 
morselized (through separate skin or fascial incision) (List separately in addition to code for primary 
procedure). 
 
We find that CPT codes 20939 and 20937 are not supported in the medical record. Specifically, the operative 
report does not contain documentation of bone marrow aspiration for bone grafting for spine surgery to support 
code 20939. The operative report does not contain documentation of an autograft for spine surgery only to 
support code 20937. Based on this information, we decided that Medicare rules for coverage of these services 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 20939-RT and 
20937 billed for October 6, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 12, 2022, to 
September 10, 2022. 
 
You asked the Plan to pay for the billed services. You say that the final claim complies with billing guidelines. 
The Plan denied your request. The Plan says the value code is missing or invalid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. The claim submitted does not include a value code as required. Based on 
this information, we decided that Medicare rules for coverage of the billed services have not been met. 
Therefore, we decided that the Plan does not have to pay for the home health services provided from August 
12, 2022, to September 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81207, 81208, and 81170 billed for August 
15, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 81207, 81208, and 81170 are not supported. 
 
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 81207 is BCR/ABL1 (t(9;22)) (eg, chronic myelogenous 
leukemia) translocation analysis; minor breakpoint, qualitative or quantitative. The definition of code 81208 is BCR/ABL1 (t(9;22)) (eg, chronic myelogenous leukemia) translocation analysis; other breakpoint, qualitative 
or quantitative. The definition of code 81170 is ABL1 (ABL proto-oncogene 1, non-receptor tyrosine kinase) 
(eg, acquired imatinib tyrosine kinase inhibitor resistance), gene analysis, variants in the kinase domain. 
 
We find that CPT codes 81207, 81208, and 81170 are not supported in the medical record. Specifically, the 
codes represent one component each of the testing and there is a more appropriate and comprehensive code for 
these services. Based on this information, we decided that Medicare rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 81207, 81208, and 
81170 billed for August 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83520 billed for date of service April 11, 
2022. 
 
You asked the Plan to pay for procedure code 83520. You say that this service is supported as billed. The Plan 
denied your request. The Plan says this code is not supported in the medical record, and the service provided 
would be better reported with 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 83520 is immunoassay for analyte other than infectious agent antibody or infectious agent antigen; 
quantitative, not otherwise specified. 
 
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 procedure code 83520. Our reviewer says that this code is 
not supported in the medical record. Our reviewer found there was no sample taken or results for immunoassay 
for analyte documented in the medical records. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 83520 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 83520 billed for date of service April 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power seat elevation feature (E2300). 
 
You asked the Plan to pre-approve the power seat elevation feature. You say that the requested item is 
medically necessary. The Plan denied your request. The Plan says that the power seat elevation feature is not 
covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve the power seat elevation feature (E2300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a below knee flex cover system. 
 
You asked the Plan to pre-approve a below knee flex cover system. You say that the enrollee requires 
additional prosthetic protection due to their motorcycle usage. You say that upon positioning on the 
motorcycle, the prosthetic socket makes direct contact with the motorcycle frame, posing potential for 
unnecessary wear and damage. You also say that an additional cover is needed to ensure that the prosthesis is 
not compromised if the patient should encounter poor weather and environments involving mud, gravel, dirt or 
other particles that could inhibit prosthetic functioning. The Plan denied your request. The Plan says the notes 
do not show why the requested extra cover is needed. 
 
The Plan follows Medicare rules. Medicare rules say that protective outer surface covering systems are 
specialized covers intended to be worn over an existing prosthesis who has special needs for protection against unusually harsh environmental situations where it is necessary to protect the lower limb prosthesis beyond the 
level of protection that is afforded by standard coverings. 
 
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 below knee flex cover system. Our 
reviewer says that the requested below knee flex cover system is not medically necessary. Our physician 
reviewer found the provided documentation does not reveal that the enrollee has special needs for protection 
against unusually harsh environmental situations where it is necessary to protect the lower limb prosthesis 
beyond the level of protection that is afforded by standard cover therefore the protective outer surface covering 
represented by code L5962. Therefore, the reviewer found that the requested below knee flex cover system is 
not medically 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 a below knee flex cover system have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a below knee flex cover system.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 7, 2022, billed with 
codes 81314 and 81345. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. 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 
October 7, 2022, billed with codes 81314 and 81345.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) 
provided on November 15, 2022. 
 
You asked the Plan to pay for the limited oral evaluation. You say that you would like the insurance to pay and 
you never had to pay before. You also say that your income is low and you have Medicare and Medicaid. The 
Plan denied your request. The Plan says this service is covered only when performed by an oral surgeon. 
 
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 limited 
oral evaluation - problem focused (D0140) provided on November 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve the bone marrow aspirate. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the 
setting of spinal fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no specific indication provided to support the request for bone marrow aspirate for the approved surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to 
support the use of bone marrow aspirate for this enrollees medical condition as discussed above. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested bone marrow aspirate in the setting of spinal fusion, in this 
case, is not medically reasonable or 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 bone marrow aspirate have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the bone marrow aspirate (20939).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visit to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve office visit. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says the plan does not cover out-of-network services 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 
office visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you need this item to make it 
easier to run errands. The Plan denied your request. The Plan says duplicate items are not covered. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a stationary concentrator with E-tanks for portability. a stationary concentrator 
with E-tanks for portability serves the same purpose as a portable oxygen concentrator. Therefore, we decided 
that the Plan does not have to pre-approve a portable oxygen concentrator (E1392).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99442 billed for date of service November 
15, 2022. 
 
You asked the Plan to pay for the billed services. You say that no bundling exists for this code. The Plan denied 
your request. The Plan says the provider did not bill as required. 
 
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 99442 is telephone evaluation and management (E/M) 
service by a physician or other qualified health care professional who may report evaluation and management 
services provided to an established patient, parent, or guardian not originating from a related E/M service 
provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or 
soonest available appointment; 11-20 minutes of medical discussion We find that a related evaluation and management service was provided within the previous 7 days. Based on 
this information, we decided that Medicare rules for coverage of the billed services have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99442 billed for date of service 
November 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve proton beam therapy. You say that this is medically necessary and the 
superior care for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria 
for this procedure. 
 
The Plan follows Medicare rules. Medicare rules state that proton beam therapy may be covered for specified 
conditions if applicable criteria are met. 
 
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 proton beam therapy. Our reviewer says 
that the enrollee does not meet criteria for the requested proton beam therapy. Our physician reviewer found 
intensity-modulated radiation therapy (IMRT) can safely delivery therapeutic doses to the prostate and seminal 
vesicles. IMRT coupled with image-guided radiation therapy (IGRT) offers very precise delivery. The target is 
not a primary lesion or metastasis. The appeal letter does address why proton beam radiotherapy is considered 
the treatment of choice for the enrollee. The enrollee does not meet any of the Group 2 covered conditions. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve multiple teeth extractions. 
 
You asked the Plan to pre-approve teeth extractions. You say that you need these teeth removed before you can 
have your knee surgery. The Plan denied your request. The Plan says this 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 pre-approve 
multiple teeth extractions.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prophylaxis - adult (D1110) provided on December 12, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that you needed to wait 6 
months after the previous visit to get the service provided on December 12, 2022. 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 June 29, 2022. Therefore, 
we decided that the Plan does not have to pay for a prophylaxis - adult (D1110) provided on December 12, 
2022.