Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service April 12, 
2022. 
 You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says an appropriate modifier was not billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code.  
 
In this case, we have confirmed that code 76700 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 76700 
billed for date of service April 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5212). 
 
You asked the Plan to pre-approve a partial denture. You say that this service is medically necessary. The Plan 
denied your request. The Plan says a mandibular partial denture (D5212) is 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 pre-approve a 
mandibular partial denture (D5212).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the requested Prolia is medically necessary. The Plan 
denied your request. The Plan says the requested Prolia is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the 
requested Prolia is not medically necessary. Our physician reviewer found the record indicates that the enrollee 
has a diagnosis of age-related osteoporosis without pathological fracture. The record provided is insufficient to 
establish that the enrollee has osteoporosis at high risk for fracture, defined as a history of osteoporotic fracture, 
or multiple risk factors for fracture; or patients who have failed or are intolerant to other available osteoporosis 
therapy. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's 
condition. The Medicare approved drug compendia do not contain a supportive citation for the use of the 
requested drug in the enrollee's clinical situation. The elements of the coverage criteria are not satisfied. The 
requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular implant/abutment supported removable
denture (D6111).
You asked the Plan to pre-approve a mandibular implant/abutment supported removable denture. The Plan
denied your request. The Plan says this service is not covered under your benefit plan.
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 requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a
mandibular implant/abutment supported removable denture (D6111).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infrared therapy services (97026) provided on March 1, 
2022. 
 
You asked the Plan to pay for the infrared therapy services. You say that these services were medically 
reasonable and necessary. The Plan denied your request. The Plan says infrared therapy is not covered by 
Medicare or the Plan. 
 The Plan must follow Medicare rules. Medicare rules say that the use of infrared therapy devices and any 
related accessories is not reasonable and necessary. Based on this information, we decided that Medicare rules 
for coverage of the infrared therapy services have not been met. Therefore, we decided that the Plan does not 
have to pay for the infrared therapy services (97026) provided on March 1, 2022.
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 need the supplies for day-to-day 
living. The Plan denied your request. The Plan says the items are 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.  
 
We looked at the file and the rules. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular gene panel provided on December 14, 
2021. 
 You asked the Plan to pay for the testing services. You say that the denied codes are payable as billed. The Plan 
denied your request. The Plan says the services are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the beneficiary's medical documentation.  
 
We looked at the file and Medicare rules. The medical records provided do not clearly document the 
physicians intent for the testing to be completed. The case file shows that the enrollees treating physician did 
not order the testing. Based on this information, we decided that the Medicare rules for coverage have not been 
met. Therefore, we decided that the Plan does not have to pay for the cardiovascular gene panel provided on 
December 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam CT capture (D0367) provided by a participating 
provider on March 24, 2022. 
 
You asked the Plan to pay for a cone beam CT capture. You say that you feel like the Plan should pay for this. 
The Plan denied your request. The Plan says the rendered dental work 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 a cone 
beam CT capture (D0367) provided by a participating provider on March 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service December 
30, 2021. 
 
You asked the Plan to pay for procedure code 93042. You say that the services were medically necessary. The 
Plan denied your request. The Plan says payment for code 93042 is bundled into payment for code 12001. 
 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 93042 
is a column II code to column I code 12001. 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 93042 billed for date of service December 30, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of an implant body (D6010), 
implant supported crown (D6066), and custom fabricated abutment (D6057). 
 
You asked the Plan to pre-approve the dental implant services. You say that these dental services are necessary 
for your condition. The Plan denied your request. The Plan says these dental services are not covered under the 
supplemental dental 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 the 
surgical placement of an implant body (D6010), implant supported crown (D6066), and custom fabricated 
abutment (D6057).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hospital observation care provided on May 
30, 2022. 
 
You asked the Plan to waive the copayment for the observation care. You say that you believe you should be 
considered an inpatient since you stayed overnight. 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 $300 
copayment per stay for outpatient hospital observation services.  
 
The file does not show evidence that an inpatient order was made by the provider, which makes the stay an 
observation stay. Therefore, you have been asked to pay a $300 copayment for the observation care. The 
observation care falls within the Outpatient Hospital Observation 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 hospital observation care provided on May 30, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9128 billed for date of service January 9, 
2022, to January 14, 2022. 
 
You asked the Plan to pay for procedure code S9128. You say that there is a Letter of Agreement for the 
services provided in this case. You also say that this should be reprocessed and paid. The Plan denied your 
request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9128 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S9128 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9128 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9128 billed for date of service January 9, 2022, to January 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 25, 2021, billed with 
codes 81206, 81292 and 81301. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says a panel code should be billed rather than the individual gene codes. 
 
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 25, 2021, billed with codes 81206, 81292 and 81301.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 9, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that there is no agreement that the codes billed 
are included in the dialysis rate. The Plan denied your request. The Plan says the tests are included in the 
dialysis rate. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flex-walk system. 
 
You asked the Plan to pre-approve a flex-walk system. You say that this equipment is medically necessary for 
the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules say that a flex-walk system or equal (L5981) is covered for beneficiaries 
whose functional level is 3 or above.  
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 flex-walk system. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that you are a 50-year-old male with a medical history of diabetes mellitus type II, 
hypertension, peripheral artery disease and joint pain. A prosthetic clinical note dated May 18, 2022, indicated 
that you underwent a right transtibial amputation 2 months prior. You also have a history of a hip dislocation at 
the age of 13 which required surgery. You are independent with transfers and your range of motion and motor 
strength were noted to be normal.  
 
The documentation provided does not support the use of the Ossur Flex-Foot Assure prosthetic foot ankle. 
There is insufficient documentation regarding the patients potential K level. A clinical progress note dated 
August 2, 2022, indicates that a wound vac is in place. The prosthetic evaluation indicates that your limb was 
still bandaged and that you were to be evaluated by home physical therapy. There is no specific grading of 
motor strength or range of motion for each joint. There is no evaluation by physical therapy indicating your 
functional level. There is insufficient documentation regarding your current functional status and you have the 
potential to be a K3 level ambulator as required for the requested equipment. 
 
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 flex-walk system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a flex-walk system.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on March 2, 2022. 
 
You asked the Plan to pay for the ambulance service. You say that you thought you were suffering a stroke. 
You say that you feel this should be covered as you were in a great deal of distress. You also say that you 
should only be responsible for the copayment at most. The Plan denied your request. The Plan says since no 
transport was provided, there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 2, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport, (A0998) provided on March 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services provided on December 1, 
2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed 
service cannot be verified. 
 
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 99152 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; initial 15 minutes of intraservice time, patient age 
5 years or older. We find that CPT code 99152 is not supported in the medical record. Specifically, the medical records provided 
do not show that the sedation services required the presence of an independent trained observer. 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 the moderate sedation services provided on December 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral-periapical first radiographic image (D0220), 
intraoral-periapical additional radiographic images (D0230 x 2), bitewings-four radiographic images (D0274), 
periodic oral evaluation (D0120), and the dental cleaning (D1110) provided on April 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. 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 dental services from an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the services provided 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 the 
intraoral-periapical first radiographic image (D0220), intraoral-periapical additional radiographic images 
(D0230 x 2), bitewings-four radiographic images (D0274), periodic oral evaluation (D0120), and the dental 
cleaning (D1110) provided on April 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided by an out-of-network provider 
from September 16, 2021, to December 28, 2021. 
 
You asked the Plan to pay for the dental services. You say that the enrollee needed to go to hospital for the 
dental work in order to undergo full anesthesia due to the enrollee's health conditions. You say you did not 
know approval was needed. 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 the dental services provided by an out-of-network provider from September 16, 2021, to December 
28, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the gene panel testing provided on February 11, 2022. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says that the 
documentation does not support the testing on the billed date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. We find that the testing was billed with a date of service indicated the date 
the test was performed. The medical records show that the Medicare rules for coverage of the testing services 
have been met. Therefore, we decided that the Plan has to pay for the gene panel testing provided on February 
11, 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.