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

 
We decided that the Plan does not have to pre-approve codes D6010 x4, D6058 x3, D6740 x8, D6245 x2, 
D2950 x1, D0171 x5, D6973 x7, D7953 x1, D9610 x1, or D4265 x2. 
 
You asked the Plan to pre-approve these dental services. The Plan denied your request. The Plan says your 
benefits for the services represented by dental codes D6010, D6058, D6740, D6245, and D2950 have already 
been exhausted. The Plan also says that dental codes D0171, D6973, D7953, D9610 and D4265 are not covered 
by the Plan's dental benefits. 
 
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. 
 
The record shows that the Plan approved coverage for code D6010 on tooth #2 and #4. The record shows that 
the Plan approved coverage for code D6058 on tooth #2 and #4. This exhausted your benefit limit for codes 
D6010 and D6058. Therefore, we decided that the Plan does not have to pre-approve additional surgical 
placements of endosteal implants (D6010 x4) or additional abutment supported porcelain/ceramic crowns 
(D6058 x3). 
 
The record shows that the Plan approved coverage of code D6740 on tooth #2 and #4 and of code D2740 on 
tooth #6. This exhausted your benefit limit for codes D6740 and D6245. Therefore, we decided that the Plan 
does not have to pre-approve additional retainer crowns - porcelain/ceramic (D6740 x8) or pontic - 
porcelain/ceramic (D6245 x2). 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the services represented by dental 
codes D0171, D4265, D9610, D7953, and D6973 are not listed as covered procedure codes. Therefore, we 
decided that the Plan does not have to pre-approve re-evaluations - post-operative office visit (D0171 x5), core 
build up for retainer, including any pins (D6973 x7), bone replacement graft for ridge preservation - per site 
(D7953 x1), therapeutic parenteral drug, single administration (D9610 x1), or biologic materials to aid in soft 
and osseous tissue regeneration, per site (D4265 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for alveoloplasty (D7311), extractions (D7210) and therapeutic 
parenteral drug, single administration (D9610) provided on January 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your $2,000 annual maximum 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 your annual maximum was exhausted and therapeutic parenteral drug is not a covered benefit. 
Therefore, we decided that the Plan does not have to pay for alveoloplasty (D7311), extractions (D7210) and 
therapeutic parenteral drug, single administration (D9610) provided on January 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an immediate denture and extractions (D7140, D7210, 
D5130) provided on November 21, 2022, to December 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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. Immediate 
partial dentures are not among those covered in this benefit. The record shows your benefit for extractions was 
exhausted on date of service November 21, 2022 to December 13, 2022. Therefore, we decided that the Plan 
does not have to pay for an immediate denture and additional extractions (D7140, D7210, D5130) provided on 
November 21, 2022, to December 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI).  
 
You asked the Plan to pre-approve SSBCI benefits. You say that The Plan denied your request. The Plan says 
the criteria for eligibility have not been met.  
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that the enrollee does not have 
an eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to 
pre-approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from December 7, 2022, to 
December 28, 2022. 
 
You asked the Plan to pay for the psychotherapy. You say that the claim from the same provider in the prior 
month was paid by the Plan. The Plan denied your request. The Plan says this provider is not part of the 
Medicare program. 
 
The Plan must follow Medicare rules. Medicare rules say that a Mental Health Counselor 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 Mental Health Counselor. 
Medicare says that a Mental Health Counselor is not eligible to participate in the Medicare program. Therefore, 
we decided that the Plan does not have to pay for psychotherapy provided from December 7, 2022, to 
December 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 21, 2022, billed 
with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328 and 81335. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were medically necessary. 
The Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
December 21, 2022, billed with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 
81328 and 81335.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One.  
You asked the Plan to pre-approve Gel-One. You say that Gel-One is medically necessary. The Plan denied 
your request. The Plan says a trial of Orthovisc and Synvisc is required before alternatives can be considered. 
 
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 Gel-One. Our reviewer says that this 
drug is not medically necessary. Our physician reviewer found the records show no trial of the plan preferred 
drugs or any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed with code 0117U for date of service 
October 17, 2022. 
 
You asked the Plan to pay for code 0117U. You say that this lab service was medically necessary. The Plan 
denied your request. The Plan says code 0117U is non-covered. The Plan must follow Medicare rules. 
Medicare rules say that lab services billed with code 0117U are non-covered for pharmacogenetic testing.  You 
billed the lab services in dispute with code 0117U, so this is a non-covered service. Therefore, we decided that 
the Plan does not have to pay for lab services billed with code 0117U for date of service October 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services billed with codes 93040, 93790, 36000, 
99070, 99072, A4615, and A4930 for date of service August 24, 2022. 
 
You asked the Plan to pay for codes 93040, 93790, 36000, 99070, 99072, A4615, and A4930. You say that 
these codes are supported by the medical records. The Plan denied your request. The Plan says code 93040 is 
not separately reportable because it is considered integral to the procedure. In addition, there is no 
documentation of an interpretation and report for this code, so it is not supported. Code 93790 requires review 
with interpretation and report, but the documentation does not support this. The Plan also says that code 36000 is included in code 96365 and is not separately reportable. Finally, the Plan says that codes 99070, 99072, 
A4615, and A4930 are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
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 codes 93040, 93790, 36000, 99070, 99072, A4615, and 
A4930. Our reviewer says that codes 93040, 93790, and 36000 are not supported by the medical record. Our 
reviewer found for code 93040, this code required an order to investigate an arrhythmia and requires a separate 
signed report. It is not to be used for reviewing telemetry strips. The records in this case indicate the patient 
was hooked up to an ECG for monitoring purposes only. This is not separately reportable. For code 93790, the 
record does not contain evidence that ambulatory blood pressure monitoring for 24 hours or longer was 
performed. There is no mention of monitoring after the procedure was completed, or a report and interpretation 
for 24 hours of monitoring. For code 36000, the only mention of needle or catheter insertion was for the 
infusion, and it is included in this procedure per coding and NCCI rules. 
 
In addition, codes 99070, 99072, A4615, and A4930 have a status indicator of N, meaning that these codes are 
packaged into payment for other services and no separate payment is made.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 93040, 93790, 36000, 99070, 99072, A4615, and A4930 have not been 
met. Therefore, we decided that the Plan does not have to pay for medical services billed with codes 93040, 
93790, 36000, 99070, 99072, A4615, and A4930 for date of service August 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve the CGM and supplies. You say that the items should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the items denied correctly as you do not 
meet the clinical requirements to be approved. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
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 CGM and supplies. Our reviewer 
says that the items are not medically necessary. Our physician reviewer found the enrollee does not meet the 
clinical requirements to be approved. 
 
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 CGM and supplies have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a continuous glucose monitor (CGM) and supplies.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 
31, 2022. 

You asked the Plan to pay for procedure code 70450. You say that this should be paid for. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 70496.
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service December 31, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from November 4, 2022, to 
December 3, 2022. 
 You asked the Plan to pay for the home health services. You say that you have provided a NOA and medical 
records. The Plan denied your request. The Plan says the NOA was not received timely. As such, this final 
claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 11, 2022. The NOA was not received by the Plan until March 17, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from November 4, 2022, to December 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone marrow aspirate (20930). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the setting of 
spinal fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no specific indication provided to support the request for bone marrow aspirate for the approved surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use 
of bone marrow aspirate for this enrollees medical condition as discussed above. No compelling rationale is 
presented, or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the request for requested bone marrow aspirate in the setting of spinal fusion in this case, is not 
medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the bone marrow aspirate (20930).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental service (D6241). 
 
You asked the Plan to pre-approve the dental service (D6241). You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the service is not a 
covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
dental service (D6241).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical eye examination provided by Jeffrey A. Jones, 
OD, on September 20, 2022. 
 
You asked the Plan to pay for the medical eye examination. You say that you were out of town caring 
for you sister and were overdue for your eye exam. You say you would like to be reimbursed for this service. 
The Plan denied your request. The Plan says the provider has opted out of Medicare services. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
medical eye examination on September 20, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99285 billed for date of service January 8, 2023. 
 
You asked the Plan to pay for code 99285. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says you billed incorrect diagnosis codes for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that that some diagnosis odes indicate laterality, 
specifying whether the condition occurs on the left, right or is bilateral. If no bilateral code is provided and the 
condition is bilateral, providers should bill separate codes for both the left and right side.  If there is a bilateral 
code, the provider should bill the bilateral code instead of the right and left codes. 
 
In this case, you billed with diagnosis code R22.41 (Localized swelling, mass and lump, right lower limb) and 
code R22.42 (Localized swelling, mass and lump, left lower limb). Because this condition was present 
bilaterally, you should have instead billed a bilateral diagnosis code (R22.43- Localized swelling, mass and 
lump, lower limb, bilateral.)  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 99285 have not been met. Therefore, we decided that the Plan does not have to pay for code 
99285 billed for date of service January 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9348 billed for date of service November 9, 
2022 to November 15, 2022. 
 
You asked the Plan to pay for procedure code S9348. You say that the Plan terminated your contract in error. 
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 S9348 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9348 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9348 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9348 billed for date of service November 9, 2022 to November 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (E2103) and 
supply allowance for the CGM (A4239). 
 
You asked the Plan to pre-approve a CGM and supply allowance for the CGM. You say that the enrollee's 
fingers are very damaged because of their Raynaud's syndrome condition. The Plan denied your request. The 
Plan says this request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of a CGM and supply allowance for the CGM have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a continuous glucose monitor (CGM) (E2103) and supply allowance for the CGM 
(A4239).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0482) provided on December 15, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the records do not support the billed 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 G0482 is Drug Testing, Definitive, 15 to 22 Drug classes. 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, the records do not support 
that at least 15 drug classes were tested. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services (G0482) provided on December 15, 2022.