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

 
We decided that the Plan has to pre-approve a crown - porcelain/ceramic (D2740) Tooth #27 and 28 and 
prefabricated post and core in addition to crown (D2954) Tooth #27. 
 
You asked the Plan to pre-approve dental services. You say that the enrollee needs the requested services to 
prevent future damage. The Plan denied your request. The Plan says that crown criteria has not been met. 
 
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 dental 
services 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 dental services. Our reviewer says that 
the service is medically necessary. Our physician reviewer found a review of the documentation indicates that, 
root canal treatment has been completed on tooth #'s 27 and 28. The crowns in place on these teeth are 
defective with recurrent caries and open margins. A post/core for tooth #27 and replacement crowns for teeth 
#'s 27 and 28 are medically reasonable and necessary to provide adequate retention and support for the 
remaining tooth structure. 
 
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 dental services have been met. Therefore, we decided that the Plan has to pre-
approve a crown - porcelain/ceramic (D2740) Tooth #27 and 28 and prefabricated post and core in addition to 
crown (D2954) Tooth #27.  
  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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is insufficient evidence to determine that radiofrequency ablation of the 
basivertebral nerve improves health outcomes. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is no magnetic resonance imaging (MRI) showing only modic changes. There was no 
facet degenerative joint disease (DJD) and foraminal stenosis. 
 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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on November 
22, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on November 22, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the anti-reflective coating (V2750), progressive lenses (V2781), and 
polycarbonate or equal lenses (V2784) purchase on January 25, 2023. 
 
You asked the Plan to pay for the anti-reflective coating, progressive lenses, and polycarbonate or equal lenses. 
You say that the insurance states the $200 will be paid toward glasses per year, but no amount was paid on this 
claim. The Plan denied your request. The Plan says that this benefit has been exhausted. 
 
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. The records do not support that your $200 eyewear allowance has been 
exhausted. This means that the Plan has not provided a valid reason for denying payment of the anti-reflective 
coating, progressive lenses, and polycarbonate or equal lenses. No payment information was provided showing 
the Plan paid the $200 allowance, exhausting the benefit. It is the burden of the Plan to substantiate their denial 
with evidence. In this case, the denial has not been substantiated. Therefore, we decided that the Plan has to pay 
for the anti-reflective coating (V2750), progressive lenses (V2781), and polycarbonate or equal lenses (V2784) 
purchase on January 25, 2023.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sales tax (S9999) provided on November 30, 2022. 
 
You asked the Plan to pay for the sales tax. The Plan denied your request. The Plan says Medicare does not 
reimburse separately for sales tax. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not make separate payment for 
sales tax. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the sales tax have not been met. Therefore, we decided that the Plan does not have to pay for the 
sales tax (S9999) provided on November 30, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service January 1, 
2023, to January 28, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
ordered by a network doctor. 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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service January 1, 2023, to January 28, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neuroplasty, major peripheral nerve, arm or leg, open; sciatic 
nerve rendered on December 22, 2022. 
 
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 records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the records do not support CPT 
64712 as a separate and distinct procedure from CPT 27399. The procedure details cite the sciatic nerve was 
identified. The fat between the popliteal vein and artery and the nerve was opened and there was an area of 
tissue which was herniated. However, a clearly defined/neoplastic appearing fatty tissue was not appreciated. 
The fat around the sciatic nerve at this level was excised medially and laterally for a distance of approximately 
8-10cm. The procedure notes the fat around the nerve was excised and therefore, was essentially part of the 
part of the procedure CPT 27399. The nerve was free without excessive tension. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for neuroplasty, major peripheral nerve, arm or leg, open; sciatic nerve rendered on December 22, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service January 25, 
2023. 
 
You asked the Plan to pay for procedure code 81345. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says payment for code 81345 is bundled into payment for 
code 0089U. 
 
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 81345 
is a column II code to column I code 0089U. 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 81345 billed for date of service January 25, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator for 4-12 months (E0466). 
 
You asked the Plan to pre-approve a ventilator for 4-12 months. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator for 4-12 months. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found continuation of the 
home ventilator is not medically necessary. The ventilator is being used in pressure support mode. The records 
do not show that bilevel positive airway pressure (BiPAP) has been tried and failed as an outpatient. Medicare 
does not cover a home ventilator for the treatment of obesity hypoventilation syndrome, or when used at 
settings that can be provided with BiPAP. Of note, the plan has approved the current home ventilator for 3 
months to allow time for transition to BiPAP. 
 
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 ventilator for 4-12 months have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a ventilator for 4-12 months (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical supplies billed with code A6212 provided on 
October 26, 2022. 
 
You asked the Plan to pay for procedure code A6212. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the documentation requirements have not been 
met.  

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid physician order for the supplies provided in this case. 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 medical supplies billed with code A6212 provided on 
October 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown (D2740) and core buildup (D2950) for tooth 5 
provided on February 6, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the dental services were necessary to 
provide a solid foundation for a new crown. The Plan denied your request. The Plan says your annual 
maximum benefit for the year 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 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 the Plan paid $304 for dental services on January 24, 2023. On February 6, 2023, the Plan paid $696 for 
dental services. For the year of 2023 the Plan paid $1,000 ($304 paid + $696 paid) for dental services; 
therefore, your annual maximum dental benefit for the year of 2023 was exhausted on the date of service of 
February 6, 2023. Therefore, we decided that the Plan does not have to pay more for a crown (D2740) and core 
buildup (D2950) for tooth 5 provided on February 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve clothing guards for dual post armrests (K0108x2). 
 
You asked the Plan to pre-approve wheelchair accessory. You say that you disagree with the denial and 
submitted medical documentation to support the need of the custom medical equipment being requested for the 
enrollee. The Plan denied your request. The Plan says the requested items are considered a convenience item 
per Medicare. 
 
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. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve clothing guards for dual post armrests (K0108x2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intravenous Infusion, hydration; each additional hour (list 
separately in addition to code for primary procedure) (96361). 
 
You asked the Plan to pay for the outpatient services. You say that you are appealing the denied charge 96361 
with a copy of the medical records for review. The Plan denied your request. The Plan says this service is 
considered not reasonable and necessary. the clinical record does not document a diagnosis that supports 
medical necessity for these services.  
 
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 96361 is intravenous infusion, hydration; each additional 
hour (list separately in addition to code for primary procedure). 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the outpatient services. Our reviewer says that the requested 
items/services are not supported in the medical records. Our reviewer found based on the documentation 
provided, the billing of CPT 96361 is not supported. The enrollee received 500 milliliters (ml) of fluid over the 
course of an hour. This should be billed as CPT 96360. There is no evidence that additional infusion time was 
provided. As such, the billing of CPT 96361 is not supported. Note:  If it took a couple of minutes for the nurse 
to start, stop and/or document the infusion, this is not actual infusion time. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the outpatient services have not been met. Therefore, we decided that the Plan 
does not have to pay for intravenous Infusion, hydration; each additional hour (list separately in addition to 
code for primary procedure) (96361).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on 
February 01, 2023. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that this provider is in-network 
and should not have a copayment. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $5 
copayment for in-network outpatient lab services.  
You have been asked to pay a $5 copayment for the laboratory services. This item/service falls within the in-
network outpatient lab services 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. The records show the proper in-network copayment was applied. Therefore, we 
decided that the Plan does not have to waive the copayment for the laboratory services provided on February 
01, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service December 15, 2022. 
You asked the Plan to pay for the billed services. You say that the treatment sought was medically necessary. 
The Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the 
required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. A review of the claim does not show that the required unique 
identifier was reported. The panel testing was not billed with a single 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 lab testing billed for date of service December 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extended neuropsychological testing (codes 96133 and 
96137). 
 
You asked the Plan to pre-approve extended neuropsychological testing. You say that this is very important for 
the enrollee. The Plan denied your request. The Plan says there is no medical necessity for extended testing. 
 
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 extended neuropsychological testing. 
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 documentation that the 8 hours of approved neuropsychological testing are inadequate for evaluation of the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of extended neuropsychological testing have not been met. Therefore, we decided 
that the Plan does not have to pre-approve extended neuropsychological testing (codes 96133 and 96137).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 87899 and 87900, provided 
September 30, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that this test was ordered based upon the treating 
physicians clinical training and medical necessity.  The Plan denied your request. The Plan says the records do 
not support the billed services 87899 and 87900. 
 
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 87899 is infectious agent antigen detection by immunoassay with direct optical (i.e., visual) observation and 87900 is infectious agent drug susceptibility 
phenotype prediction using regularly updated genotypic bioinformatics.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the laboratory services. Our reviewer says that the billed 
codes are not supported in the provided the medical records. Our reviewer found the documentation submitted 
was reviewed and does not meet criteria. For CPT 87899, the laboratory report does not include documentation 
to support rapid test kit that shows collected samples of the infection agent, by a swab or aspirations using 
several reagents. For CPT 87900, the laboratory report does not include documentation to support quantitative 
prediction of the drug susceptibility phenotype for each antiretroviral drug with a numeric measure and 
assessment, and therefore the billed services cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services coded as 87899 and 87900, provided September 30, 2022.