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

 
We decided that the Plan does not have to pre-approve tooth molds (D0470), local anesthesia (D9215), 
temporary crowns (D2799) for teeth numbers 24, 25, and 26, a false tooth for bridge (D6240) for tooth number 
24 and a white glass cap (D6750) for teeth numbers 25 and 26. 
 
You asked the Plan to pre-approve tooth molds (D0470), local anesthesia (D9215), temporary crowns (D2799) 
for teeth numbers 24, 25, and 26, a false tooth for bridge (D6240) for tooth number 24 and a white glass cap 
(D6750) for teeth numbers 25 and 26. You say that you have a missing tooth and in order to replace or to have 
the bridge, you need to have bite analysis and mold done. The Plan denied your request. The Plan says tooth 
molds (D0470), local anesthesia (D9215), and temporary crowns (D2799) are not covered by the plan. The 
Plan also says that a false tooth for bridge (D6240), and a white glass cap (D6750) were denied as not 
medically necessary.  
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 a false tooth 
for bridge (D6240) and a white glass cap (D6750) when the services are medically necessary and reasonable.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, tooth molds (D0470), local anesthesia 
(D9215), temporary crowns (D2799) are not among those covered under this benefit.  
 
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 tooth molds (D0470), local anesthesia 
(D9215), temporary crowns (D2799) for teeth numbers 24, 25, and 26, a false tooth for bridge (D6240) for 
tooth number 24 and a white glass cap (D6750) for teeth numbers 25 and 26. Our reviewer says that the 
provided documentation does not supply sufficient information to allow for a determination of necessity for the 
bridge requested. Our physician reviewer found that the requested bridge does not meet the Plan criteria. Our 
physician reviewer also found that it appears possible to replace tooth number 25 with a removable appliance 
as well as the other missing posterior teeth in the lower right quadrant at the same time. 
 
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 tooth molds (D0470), local anesthesia (D9215), temporary crowns (D2799) for 
teeth numbers 24, 25, and 26, a false tooth for bridge (D6240) for tooth number 24 and a white glass cap 
(D6750) for teeth numbers 25 and 26 have not been met. Therefore, we decided that the Plan does not have to 
pre-approve tooth molds (D0470), local anesthesia (D9215), temporary crowns (D2799) for teeth numbers 24, 
25, and 26, a false tooth for bridge (D6240) for tooth number 24 and a white glass cap (D6750) for teeth 
numbers 25 and 26.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specific pneumatic compression device (E0651, 
E0667). 
 
You asked the Plan to pre-approve the device. You say that this provider is the only supplier in the patient's 
geographical area that supplies this lymphedema pump. The Plan denied your request. The Plan says medically 
necessary care is available in-network. 
 
The Plan must follow Medicare rules. Medicare rules say that contract suppliers are not required to furnish a 
specific brand name item or mode of delivery to a beneficiary unless prescribed by a physician or treating 
practitioner to avoid an adverse medical outcome.  
 
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 device. Our reviewer says that the 
requested specific brand is not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the medical records provided there is no documentation that the specific brand of 
pneumatic compression device is reasonable or necessary. Provided records do not document trial and failure 
of all standard pneumatic compression devices from an in-network provider and records do not contain any 
independent, peer-reviewed data showing superiority of the requested device over a standard device from an in-
network provider. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a specific pneumatic compression device (E0651, E0667).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service October 5, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service October 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 2, 2022. 
 
You asked the Plan to pay for the lab services. You say that you provided medical records to support payment. 
The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on September 2, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 1, 2022, to 
March 30, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this claim was timely filed, so it 
should be paid. 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 March 1, 2022, to March 
30, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 6, 2022 to 
January 31, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you have submitted the required 
NOA. 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 January 6, 2022 to 
January 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on July 15, 
2021. 
 
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 remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. Medicare rules also say that a physician order must be present for labs to be covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the services have been met. The 
provider did not send in a physician order for these services.. Therefore, we decided that the Plan does not have 
to pay for drug testing services provided to the enrollee on July 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ziextenzo. 
 
You asked the Plan to pre-approve Ziextenzo. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Ziextenzo. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of metastatic small cell lung cancer on myelosuppressive chemotherapy. The 
documentation does not support that the enrollee has tried and failed Fulphila or Neulasta. The documentation 
does not support that Fulphila or Neulasta would likely be less effective and/or likely have adverse effects for 
the enrollee. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ziextenzo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Ziextenzo.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667)  
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation in the office notes of edema that extends into the chest, trunk 
or abdomen, or that there has been a trial with the basic pump. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided records do not document any physical examination of the patient showing lymphedema 
of the chest, trunk, or abdomen. As the records do not document lymphedema of the chest, trunk or abdomen or 
trial and failure of a standard pneumatic compression pump, then it cannot be said that the enrollee has unique 
characteristics that would indicate a segmented pump over a standard pump. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0652, E0667)
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 8, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 30, 2022. 
 
You asked the Plan to pay for the lab services. You say that you provided records showing the medical 
necessity of these services. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on March 30, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia services for management of epidural or subarachnoid drug 
administration (code 01996) provided on March 2, 2022. 
 
You asked the Plan to pay for anesthesia services for management of epidural or subarachnoid drug 
administration. You say that you have provided the medical records to support coverage for this service. The 
Plan denied your request. The Plan says that this service was billed without anesthesia minutes. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a coding rule or a Medicare rule to 
substantiate their denial. Therefore, we decided that the Plan has to pay for anesthesia services for management 
of epidural or subarachnoid drug administration (code 01996) provided on March 2, 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Opioid treatment programs provided from March 6, 2022 to 
May 20, 2022. 
 
You asked the Plan to pay for Opioid treatment programs. You say that the services were medically necessary. 
The Plan denied your request. The Plan says this provider type is not eligible in the Medicare program. 
 
The Plan must follow Medicare rules. Medicare rules say that a Substance Abuse Facility is not 
eligible to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Substance Abuse Facility. 
Medicare says that a Substance Abuse Facility is not eligible to participate in the Medicare program. Therefore, 
we decided that the Plan does not have to pay for Opioid treatment programs provided from March 6, 2022 to 
May 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the automatic external defibrillator, with integrated 
electrocardiogram analysis, garment type (K0606) provided September 19, 2021. 
 
You asked the Plan to pay for the automatic external defibrillation. You say that please review and reconsider 
this claim for payment. You are asking for an extension on the timely filing limit as the transition in the 
authorization process delayed this claim. The Plan denied your request. The Plan says the claim as received 
past the timely filing limitation. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the automatic external defibrillation was not filed until November 7, 2022. 
This means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for the automatic external defibrillator, with 
integrated electrocardiogram analysis, garment type (K0606) provided September 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
supply allowance (A4595) provided August 7, 2022. 
 
You asked the Plan to pay for the TENS supply allowance. You say that according to the prescription, the 
prescribing physician recommends an extended lifetime use of the equipment as they are diagnosed with 
chronic pain and compromised mobility without the option for surgical correction. The Plan denied your 
request. The Plan says there is no evidence to support the ordering provider ordered the service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain a valid physician order, or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, the Plan made outreach to the ordering provider 
indicated and the provider's office confirmed that there were no orders in the medical records. The record 
shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, 
we decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
supply allowance (A4595) provided August 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on July 
11, 2022. 
 
You asked the Plan to pay for the nursing facility care. You say that the service was medically necessary. You 
also say that they should be covered. The Plan denied your request. The Plan says the Evidence of Benefits 
(EOB) was not received from the enrollee's primary coverage. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has called the 
enrollee and the provider in an attempt to obtain the primary Evidence of Benefits. As the secondary insurer, 
the Plan cannot be held responsible for the nursing facility care until the primary insurer has denied the claim 
for these services. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility 
care (99308) provided on July 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99215) provided on October 3, 2022. 
 
You asked the Plan to pay for the outpatient visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says an EOB was not received from the primary payer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer.  
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to bill the primary payer and sent an Evidence of Benefits (EOB). As the secondary insurer, the Plan 
cannot be held responsible for the outpatient visit until the primary insurer has denied the claim for these 
services. Therefore, we decided that the Plan does not have to pay for the office visit (99215) provided on 
October 3, 2022.