Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial nursing facility care (99306) and advance care 
planning (99497) provided January 27, 2021. 
 
 
 You asked the Plan to pay for the nursing facility care. You say that the enrollee was not covered under hospice 
on the date of service. The Plan denied your request. The Plan says Original Medicare would be responsible for 
payment of all Medicare covered services related or unrelated to the members terminal condition until the first 
day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on 01/21/2021. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the initial nursing facility 
care (99306) and advance care planning (99497) provided January 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compounded drug (J7999), the arthrocentesis services 
(20610), and ketorolac tromethamine injections (J1885) provided on December 18, 2021. 
 
You asked the Plan to pay for the medical services as billed. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this claim is a duplicate of 
a previously paid claim and was correctly denied. In addition, services have denied for a medically unlikely 
edit. 
 
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. Medicare 
rules say that claims submitted where the unit of service exceeds the MUE value are possible but medically 
highly unlikely that higher values would represent correctly reported medically necessary services when the 
MAI value is 3. 
 
We looked at the file and Medicare rules. The file includes evidence that the codes 20610 and J1885 at issue 
were reimbursed by the Plan on January 23, 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.  
 
In addition, the medical records do not provide an argument as to why the MUE was exceeded for J7999. 
Although it is possible that these services could exceed the MUE, there must be evidence to support this service 
as medically necessary. Based on this information, we decided that the Medicare rules for the medical services 
as billed have not been met. Therefore, we decided that the Plan does not have to pay for the compounded drug 
(J7999), the arthrocentesis services (20610), and ketorolac tromethamine injections (J1885) provided on 
December 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dupixent. 
 
You asked the Plan to pre-approve Dupixent. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dupixent.  
 
 
 
 Benefits for Dupixent may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (99153) provided on January 21, 2022. 
 
You asked the Plan to pay for moderate sedation services (99153). You say that the attached medical records 
should be reviewed for reconsideration. The Plan denied your request. The Plan says CPT code 99153 may not 
be paid if furnished to a hospital inpatients or patients in a hospital outpatient department. 
 
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 99153 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service). 
 
We find that CPT code 99153 is not supported in the medical record. Specifically, CPT code 99153 is a TC 
only code and the claim indicates that this service was rendered in a facility setting. Payment for CPT code 
99153 is made to the facility and is the responsibility of the facility to any physician or vendor. Based on this 
information, we decided that Medicare rules for coverage of moderate sedation services (99153) have not been 
met. Therefore, we decided that the Plan does not have to pay for moderate sedation services (99153) provided 
on January 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete upper denture (D5110) provided on March 29, 2022. 
 
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says you have exhausted the allowable benefit for the 
item provided in this case. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 item provided in this case was exhausted on date of service March 9, 2021. The Plan 
contract provides coverage of one complete upper denture every five calendar years. You previously received 
this item on March 9, 2021; which was paid for by the Plan. Therefore, the benefit for this dental item has been 
exhausted. Therefore, we decided that the Plan does not have to pay for the complete upper denture (D5110) 
provided on March 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacral lateral nerve ablation. 
 
You asked the Plan to pre-approve sacral lateral nerve ablation. You say that sacral lateral nerve ablation is 
medically necessary. The Plan denied your request. The Plan says sacral lateral nerve ablation is 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 sacral lateral nerve ablation. Our 
reviewer says that sacral lateral nerve ablation is not considered medically reasonable and necessary in this 
case. Our physician reviewer found that sacral lateral nerve ablation is considered an experimental/ 
investigational procedure due to the wide variation in efficacy in the published literature.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sacral lateral nerve ablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve sacral lateral nerve ablation.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Cosentyx pen. 
 
You asked the Plan to pre-approve Cosentyx. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Cosentyx 
pen.  
 
 Benefits for Cosentyx may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (code D4910) provided on 
December 17, 2021. 
 
You asked the Plan to pay for the dental services. You say that this was your fourth visit of the four allowed 
visits. 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 dates of service February 2, 2021, and 
August 11, 2021. Therefore, we decided that the Plan does not have to pay for periodontal maintenance (code 
D4910) provided on December 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Omeprazole. 
 
You asked the Plan to pre-approve Omeprazole. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Omeprazole.  
 
Benefits for Omeprazole may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the valvuloplasty, mitral valve, with cardiopulmonary bypass 
(33427) provided March 17, 2022. 
 
You asked the Plan to pay for the surgical services. You say that please review the attached supporting 
documentation that should make this payable. The Plan denied your request. The Plan says incorrect modifier. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 In this case, there is no documentation that a qualified resident surgeon was not available at this teaching 
institution. The operative report documents participation of a qualified resident, a 3rd year Cardiothoracic 
Surgery Fellow. Therefore, we decided that the Plan does not have to pay for the valvuloplasty, mitral valve, 
with cardiopulmonary bypass (33427) provided March 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete lower denture (D5120) provided on April 4, 2022. 
 
You asked the Plan to pay for the dental item. You say that your denture was broken. You say that you need a 
new one. You say that when you signed up for the policy you explained your issue to the agent. You say that 
you were advised this would be covered. You also say that you do not have any help. The Plan denied your 
request. The Plan says the denture is not a covered dental item. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the complete lower denture is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
complete lower denture (D5120) provided on April 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the comprehensive oral evaluation (D0150) 
provided on November 29, 2021. 
 
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not a covered 
benefit under the enrollees contractual policy. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The service you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
the enrollees teeth or the structures directly supporting the enrollees teeth. These are dental services that are 
not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to issue reimbursement 
for the comprehensive oral evaluation (D0150) provided on November 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pill dispenser. 
 
You asked the Plan to pre-approve a pill dispenser. You say that the requested item is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and a pill 
dispenser is an OTC item. Therefore, we decided that the Plan does not have to pre-approve a pill dispenser.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for laboratory testing for detecting genes 
associated with breast cancer provided on February 22, 2022. 
 
You asked the Plan to waive the cost share for the laboratory testing. You say that this was just a test, and you 
want an explanation for the 20% coinsurance. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for genetic testing.  
 
You have been asked to pay $774.60 which is 20% of the allowed amount for genetic testing ($3873 allowed 
amount x 20% = $774.60). Laboratory testing falls within the Outpatient Diagnostic Tests and Therapeutic 
Services and Supplies 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 cost share for laboratory testing for detecting genes associated 
with breast cancer provided on February 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing services provided to the enrollee on 
November 29, 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 in addition to single gene testing, panels that include the FANCC gene are a statutorily excluded 
service. 
 
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 pay for the services. Our reviewer says that  Our 
physician reviewer found that the review indicates that testing for the FANCC gene was not reasonable in this 
case. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for genetic testing services provided to the enrollee on November 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you are wearing incontinence garments 
three times a day. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
March 31, 2022, by the out-of-network provider. 
 
You asked the Plan to pay for the dental service. You say that you were due for this service as it is covered by 
insurance every six months. You say you needed to changed providers for personal reasons. You say that the 
provider in this case assured they were actively pursuing in network status with your plan. You also say that 
you feel this should be covered. The Plan denied your request. The Plan says your benefit for the 
comprehensive oral evaluation 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 comprehensive oral evaluation was exhausted on date of service March 10, 2021. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) 
provided on March 31, 2022, by the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a root canal (D3330), three crowns (D2740 x3) and a 
post and core (D2954) under your Medicare benefit. 
 
You asked the Plan to pre-approve dental services. You say that these services are necessary. The Plan denied 
your request. The Plan says these services do not meet the criteria for coverage. 
 
Medicare generally does not cover dental services. The Plan follows the same rule, but offers coverage for 
some dental services that are not covered by Medicare under your Medicaid benefits. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Although the Plan covers additional services under your Medicaid benefit, we do not 
have jurisdiction regarding Medicaid benefits. Therefore, we decided that the Plan does not have to 
pre-approve a root canal (D3330), three crowns (D2740 x3) and a post and core (D2954) under your Medicare 
benefit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6240) for tooth #4 and retainer crowns 
(D6750) for tooth #'s 3 and 5. 
 
You asked the Plan to pre-approve a pontic and retainer crowns. The Plan denied your request. The Plan says 
you are missing other teeth. The Plan also says the periodontal condition of the abutment teeth for the requested 
bridge is compromised to the extent of precluding a long-term successful result. 
 
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 pontic and 
retainer crowns 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 a pontic and retainer crowns. Our 
reviewer says that a pontic and retainer crowns are not reasonable and necessary. Our physician reviewer found 
there are three missing posterior teeth and no missing anterior teeth. The Plan provisions limit the use of 
bridgework to anterior replacement of a single tooth where there are no missing posterior teeth, and in this 
case, there are only missing posterior teeth in the upper arch. Our reviewer also found that given the criteria 
presented, there would be no necessity for the requested bridge procedures. 
 
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 a pontic and retainer crowns have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a pontic (D6240) for tooth #4 and retainer crowns (D6750) for tooth #'s 3 
and 5.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre 14-day continuous glucose monitor 
(CGM). 
 
You asked the Plan to pre-approve Freestyle Libre 14-day CGM. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested device. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
Freestyle Libre 14-day have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Freestyle Libre 14-day continuous glucose monitor (CGM).