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

 
We decided that the Plan does not have to pre-approve the crowns (D2750) and the post (D2954). 
 
You asked the Plan to pre-approve the crowns (D2750) and the post (D2954). You say that  the enrollee had a 
crown done and then needed a root canal on the tooth next to crown. The appellant states the enrollee was 
advised to go back to the dentist as she needs a second crown on top of the tooth. The Plan denied your request. 
The Plan says the crowns and the post are not medically necessary. The Plan says the x-ray submitted shows 
that the root canal treatment for tooth #30 is incomplete. 
 
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 Plan covers the crowns 
(D2750) and the post (D2954) 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 the crowns (D2750) and the post 
(D2954). Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
documentation indicates the presence of an inadequate root canal filling in tooth #30. Prior to approval for a 
post and crown the root canal must be completed to the standard of care. 
 
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 the crowns (D2750) and the post (D2954) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the crowns (D2750) and the post (D2954).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99072 billed for date of service March 23, 
2023. 
 
You asked the Plan to pay for procedure code 99072. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 99072 is considered bundled and not separately 
payable.  
 
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 99072 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99072 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99072 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99072 billed for date of service March 23, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee needs this level of care. The Plan 
denied your request. The Plan says medical records do not show that the enrollee requires care in a SNF setting.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. 
The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 
setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81003 and 87481 billed for date of service 
January 24, 2022. 
 
You asked the Plan to pay for the billed services. You say that the medical documentation supports the 
services. The Plan denied your request. The Plan says the billed codes are not supported. 
 
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 81003 is urinalysis; automated without microscopy. We 
find that code 81003 is not supported in the medical record. The documentation does not include results of a 
urinalysis.  
 
The definition of code 87481 is infectious agent detection by nucleic acid (DNA or RNA); Candida species, 
amplified probe technique. We find that 5 units of CPT code 87481 is not supported in the medical record. The 
records do not show that 5 Candida species were tested. 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 procedure codes 81003 and 87481 billed for date of service January 24, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the gastrointestinal tract imaging to be provided by an 
OON provider.  
 
You asked the Plan to pre-approve the gastrointestinal tract imaging. You say that you are requesting 
reconsideration of the denied service. The Plan denied your request. The Plan says the service was not 
approved. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the gastrointestinal tract imaging to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and the debridement procedure provided on 
January 05, 2022. 
 
You asked the Plan to pay for the office visit and the debridement procedure. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit and the 
debridement procedure provided on January 05, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
May 31, 2023. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that you say you were 
mislead, you thought you had been admitted, not observed. You should not have an ER copay. 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 $90 
copayment for emergency room services. 
 
You have been asked to pay a $90 copayment for an emergency room (ER) visit. This item/service falls within 
the emergency room 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. Therefore, we decided that the Plan does not have to waive the copayment for an 
emergency room (ER) visit provided on May 31, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiologic guidance described by 2 units of code 76942 
performed on August 21, 2023. 
 
You asked the Plan to pay for 2 units of code 76942. You say that 2 units of code 76942 should be paid as 
billed because they are supported in the documentation. The Plan denied your request. The Plan says 2 units of 
code 76942 are denied because the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that CMS payment policy allows 1 unit of service for 
76942 for a single encounter. 
 
We looked at the file and Medicare rules. In this case, 2 units of code 76942 were billed on date of service August 21, 2023. Per Medicare rules, the unit of service for code 76942 is determined by the encounter, not the 
number of lesions, aspirations, biopsies, injections, or localizations. This means that for 1 encounter, only 1 
unit of code 76942 is allowed. As such, the 2 units of 76942 billed for 1 encounter on August 21, 2023, are not 
supported. Based on this information, we decided that Medicare rules for coverage of 2 units of code 76942 
have not been met. Therefore, we decided that the Plan does not have to pay for the radiologic guidance 
described by 2 units of code 76942 performed on August 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device (L8702). 
 
You asked the Plan to pre-approve orthotic device . You say that the enrollee has been referred by their family 
practice physician for myoelectric orthotic restoration, using the MyoPro Motion G. The Plan denied your 
request. The Plan says this is considered experimental and investigational due to insufficient evidence of safety 
and efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. There are not enough studies to show MyoPro is safe and effective to 
help you recover from your disability. Based on this information, we decided that Medicare rules for coverage 
of orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
MyoPro Motion G orthotic device (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injection procedure provided on June 19, 
2023, to June 21, 2023. 
 
You asked the Plan to waive the coinsurance for injection procedure. You say that you were told you would not 
have a copay, and now you have a huge bill. 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for injection procedure. This item/service falls within the 
Medicare Part B prescription drugs 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 total you owe is $762.98 ($3,814.94 x 20% = $762.98). Therefore, we 
decided that the Plan does not have to waive the coinsurance for injection procedure provided on June 19, 
2023, to June 21, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
June 19, 2023. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you were not 
informed of the 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 $300 
copayment for ambulance services. 
 
You have been asked to pay a $300 copayment for the ambulance transportation. This item/service falls within 
the ambulance 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. Therefore, we decided that the Plan does not have to waive the copayment for the 
ambulance transportation provided on June 19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an associated brachial plexus nerve block (64415). 
 
You asked the Plan to pre-approve an associated brachial plexus nerve block. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria 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.  
 
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 an associated brachial plexus nerve 
block. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found routine post operation medictions could be given. There is no medical need for an associated bracial plexus block. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an associated brachial plexus nerve block have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an associated brachial plexus nerve block (64415).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pneumatic compression device to be provided by an 
out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the pneumatic compression device. You say that other pumps do not and 
cannot fill the prescribed order, therefor none of the in-network providers can provide this equipment. The Plan 
denied your request. The Plan says the enrollee must receive their care from a network provider (for more 
information about this, see Section 2 in Chapter 3). In most cases, care the enrollee receives from an out-of-
network provider (a provider who is not part of the plans network) will not be covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the pneumatic compression device to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9494 billed for date of service January 14, 
2023, to January 19, 2023. 
 
You asked the Plan to pay for procedure code S9494. You say that the claim is billed correctly and should be 
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 S9494 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9494 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9494 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9494 billed for date of service January 14, 2023, to January 19, 2023.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance.

You asked the Plan to pre-approve radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan follows Medicare rules. Medicare rules say that radiofrequency ablation is only covered for certain indications.

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 radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has sacroiliitis. The enrollee has tried Physical Therapy and a Home exercise program as well as Ice/Heat. The enrollee uses Voltaren gel for pain. The enrollee has had two sacroiliac joint injections with 80% pain relief. The requested services are considered experimental therapy because of the wide variation in efficacy reported in the peer reviewed literature. Therefore, the enrollee does not meet criteria for the requested services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 16, 2023, billed with 
codes 81292, 81295, 81298, 81317, 81351, 81407, 81408 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. 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 
June 16, 2023, billed with codes 81292, 81295, 81298, 81317, 81351, 81407, 81408 and 81479.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and bitewing x-rays 
(D0274) provided on July 13, 2023. 
 
You asked the Plan to pay for the dental services. You say that on the date of service the provider was in-
network with the Plan. 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 periodic oral evaluation (D0120) and bitewing x-rays (D0274) provided on July 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on June 13, 2023. 
 
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. The record 
shows your benefit for the requested item or service was exhausted on date of service February 9, 2023. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
June 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing (87801, 87798, and 87493) provided on 
February 17, 2023. 
 
You asked the Plan to pay for the panel testing. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the panel testing (87801, 87798, and 87493) provided on February 17, 2023.