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

 
We decided that the Plan does not have to pay for drug metabolism or processing (multiple conditions), whole 
blood or buccal specimen, DNA analysis, 27 gene report, with variant analysis and reported phenotypes 
provided on March 31, 2023. 
 
You asked the Plan to pay for drug metabolism or processing (multiple conditions), whole blood or buccal 
specimen, DNA analysis, 27 gene report, with variant analysis and reported phenotypes. You say that the 
genetic testing was medically necessary. The Plan denied your request. The Plan says the requested genetic 
testing does not meet the Medicare LCD coverage criteria.  
 
The Plan follows Medicare rules. Medicare rules say that drug metabolism or processing (multiple conditions), 
whole blood or buccal specimen, DNA analysis, 27 gene report, with variant analysis and reported phenotypes 
is covered when the criteria listed in the Medicare rules section of this decision are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for drug metabolism or processing 
(multiple conditions), whole blood or buccal specimen, DNA analysis, 27 gene report, with variant analysis and 
reported phenotypes. Our reviewer says that the requested genetic testing is not considered medically 
reasonable and necessary. Our physician reviewer found that the enrollee has a history of depression on 
medical therapy with Zoloft. The enrollees provider is requesting a genetic test to see how her body reacts to 
some medicines. Zoloft (sertraline) is on the special list of medicines that show they have a clinically useful 
gene-drug interaction [Clinical Pharmacogenetic Implementation Consortium category A or B drugs  
(CPIC category A and B)]. However, it is only tested with one (single) gene. It does not require a more than 
one (multi) gene panel test. In addition, the other medications the enrollee is taking are not CPIC category A 
and B. The clinical notes do not show what other medications the provider is considering and if they are CPIC 
category A and B. The review has determined that the requested genetic test does not meet the Medicare LCD 
coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of drug metabolism or processing (multiple conditions), whole blood or buccal 
specimen, DNA analysis, 27 gene report, with variant analysis and reported phenotypes have not been met. 
Therefore, we decided that the Plan does not have to pay for drug metabolism or processing (multiple 
conditions), whole blood or buccal specimen, DNA analysis, 27 gene report, with variant analysis and reported 
phenotypes provided on March 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shower chair provided on June 6, 2023.  
 
You asked the Plan to pay for a shower chair. You say that you would like reconsideration because the 
requested shower chair is medically necessary. The Plan denied your request. The Plan says this item is not 
covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pay for a shower chair provided on June 6, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient physical therapy to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve outpatient physical therapy. You say that you disagree with the denial for 
outpatient physical therapy with an out-of-network provider. The provider you are requesting is the best in the 
area. The Plan denied your request. The Plan says the service can be provided by an in-network provider. 
 
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 
outpatient physical therapy to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pontic - porcelain/ceramic (D6245), retainer crown - 
porcelain fused to high noble metal (D6750), and retainer crown - full cast high noble metal (D6790) provided 
on May 22, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were advised by the plan that there were no 
in-network providers in your area. You also say that the nearest provider was over 100 miles away. 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. The Plan also says that the records indicate that you did contact the 
plan prior to the date of service to verify benefits and were provided with the name of an in-network provider. 
 
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 pontic - porcelain/ceramic (D6245), retainer crown - porcelain fused to high noble metal 
(D6750), and retainer crown - full cast high noble metal (D6790) provided on May 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planing (D4342) for the 
lower left quadrant provided on May 4, 2023. 
 
You asked the Plan to pay for the dental services. You say that the provider called to verify the dental service 
and you were not aware of the 3-year limit. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. Also, it was verified that the provider was told the proper 
benefits and limitations. 
 
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 the Plan paid for the periodontal scaling and root planing (D4342) for the lower left quadrant on May 
13, 2022; therefore, your benefit for the requested item or service was exhausted on the date of service of May 
13, 2022. Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root planing 
(D4342) for the lower left quadrant provided on May 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the upper partial denture (D5211) provided on April 19, 
2023. 
 
You asked the Plan to pay for this dental item. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says your benefit for the dental item provided 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 dental item provided was exhausted on date of service January 21, 2020.  
  
 
 
 
 
Specifically, the Plans contract states that one upper partial denture is covered every 60 months. You 
previously received this dental item on January 21, 2020, less than 60 months prior, which was paid for by the 
Plan. Therefore, you have exhausted the allowable dental benefit for this item. Therefore, we decided that the 
Plan does not have to pay for the upper partial denture (D5211) provided on April 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377).  
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that the K0861 base and all 
recommended components are needed to meet the enrollee's current medical, mobility, and functional needs.  
The Plan denied your request. The Plan says  although there are three requested power options (tilt, recline and 
elevating leg rests), there is not a medical need to control these power options through the joystick.  
 
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 durable medical equipment (DME). 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the requested electrical accessories are not medically necessary as the 
enrollee does have use of the upper extremity and can operate and control the power options using the switches 
that are included in the basic wheelchair. There is not a medical need for the upgraded electronics. 
 
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 durable medical equipment (DME) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep sedation/general anesthesia-each subsequent 15 
minute increments (D9223 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your request exceeds the allowable 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, certain limitations apply. The record 
shows your benefit for the requested services has been previously exhausted.  
  
 
 
 
 
Specifically, the Plans contract states that the first 15 minutes of deep or moderate sedation are covered, and a 
single additional increment of 15 minutes, for a maximum of 30 minutes. The Plan has previously approved  
30 minutes of sedation for the dental extraction. Therefore, your request exceeds the allowable dental benefit. 
Therefore, we decided that the Plan does not have to pre-approve deep sedation/general anesthesia-each 
subsequent 15 minute increments (D9223 x 2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye examination (92004) provided on May 24, 
2023. 
 
You asked the Plan to pay for a medical eye examination (92004). You say that you were not aware that a 
referral was required. 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 a medical eye 
examination (92004) provided on May 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service April 13, 
2023, to April 16, 2023. 
 
You asked the Plan to pay for procedure code 99232. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 99232 is 1. The MAI value for this code is 3. You billed 4 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 99232 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99232 billed for date of service April 13, 2023, to April 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown for tooth #5 (D2750). 
 
You asked the Plan to pre-approve 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 January 6, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a crown for tooth #5 (D2750).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2790) for tooth #12 provided on April 24, 2023. 
 
You asked the Plan to pay for the dental service. You say that you had to get work done on your crown and you 
would like the Plan to reverse their decision. 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 the Plan paid for a crown (D2740) for tooth #12 on March 23, 2023; therefore, your benefit for the 
requested item or service was exhausted on the date of service of March 23, 2023. Therefore, we decided that 
the Plan does not have to pay for a crown (D2790) for tooth #12 provided on April 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the items should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says the services denied correctly as the 
enrollee does not meet the clinical requirements to be approved. 
 
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 have diabetes, 
use insulin or have a history of problematic hypoglycemia, had an in-person visit with their treating physician 
to evaluate their diabetes control and to determine whether the criteria for coverage have been met.  Based on 
this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service April 25, 
2023.  
 
You asked the Plan to pay for procedure code 88341. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88341 is 13. The MAI value for this code is 3. You billed 14 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88341 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88341 billed for date of service April 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation - diagnostic service provided by dentist or 
physician other than requesting dentist or physician (D9310) provided on May 19, 2023. 
 
You asked the Plan to pay for the consultation. You say that your back teeth are missing gum and your teeth 
are receding. You also say that you needed the dental procedure. The Plan denied your request. The Plan says 
you do not have the dental supplement benefit. The Plan also says that code D9310 is not listed as a covered 
preventive and comprehensive service dental procedure code. 
 
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 consultation - diagnostic service provided by 
dentist or physician other than requesting dentist or physician (D9310) provided on May 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infusion pump (E0781) provided on April 11, 2023. 
 
You asked the Plan to pay for the infusion pump. The Plan denied your request. The Plan says the claim was 
not billed with the required modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that claim lines billed for the above services without 
a KX, GA, or GZ modifier will be rejected as missing information.  

We looked at the file and Medicare rules. In this case, code E0781 was not billed with modifier KX as required 
by LCA A52507. Based on this information, we decided that Medicare rules for coverage of the infusion pump 
have not been met. Therefore, we decided that the Plan does not have to pay for the infusion pump (E0781) 
provided on April 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing provided on May 9, 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 a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the panel testing have not been met. Specifically, the service at issue is a test panel which was unbundled and billed as individual components. Therefore, we decided that the Plan does not have to pay for 
the panel testing provided on May 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
You asked the Plan to pre-approve a home ventilator system. The Plan denied your request. The Plan says a 
home ventilator is not medically necessary for this patient because their needs can be met with an alternative 
device such as a BiPAP device with average volume-assured pressure support (AVAPS).  
 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 a home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that the enrollee 
has COPD and chronic respiratory failure. The hospital documentation shows that BiPAP therapy was a 
success and not a failure. Also, there is no concrete data to suggest BiPAP failure, therefore a home ventilator 
is not the best practice or indicated per documentation. 
 
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 home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.