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

 
We decided that the Plan does not have to pre-approve core buildups, including any pins when required for 
teeth# 8 and 9 (D2950 x 2) and porcelain/ceramic dental crowns for teeth# 8 and 9 (D2740 x 2). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested items are not medically necessary.  
 
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 these items 
and services when 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 these items.   
 
Our reviewer says that the requested dental items are not medically necessary. Our physician reviewer found 
that the requested dental items do not appear to be reasonable or necessary. There is minimal involved missing 
or fractured structures on either tooth# 8 or 9, and a full coverage crown would be considered excessive 
treatment for this situation. A core buildup is only necessary where there is insufficient structure remaining to 
retain a crown. If a crown is not needed, a core buildup is also not required. The Plan has certain criteria for 
crown restorations which indicates that anterior teeth must have extensive caries involving four or more 
surfaces, undermining or loss of at least 50% of the incisal angle, or 50% loss of a clinical crown. In this 
instance there is an existing incisal restoration on tooth# 8 which was noted as having been replaced several 
times. The amount of involved tooth structure is about 20% on tooth# 8, and no clear loss of structure on  
tooth# 9. There would be no clear reason to place crown restorations on teeth #8 or #9. Core buildups are only 
needed where there is insufficient remaining structure to retain a crown. In this case, there is no need for a 
crown, and therefore no need for a core restoration. 
 
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 these items have not been met. Therefore, we decided that the Plan does not 
have to pre-approve core buildups, including any pins when required for teeth# 8 and 9 (D2950 x 2) and 
porcelain/ceramic dental crowns for teeth# 8 and 9 (D2740 x 2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the destruction by neurolytic agent (64636-RT) and the 
fluoroscopic guidance and localization (77003) provided on July 11, 2022.  
 
You asked the Plan to pay for the services. You say that the services should be paid. 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. 
 
In this case, the CPT Code Manual definition of code 64636 is destruction by neurolytic agent, paravertebral 
facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint 
(List separately in addition to code for primary procedure). The definition of code 77003 is fluoroscopic 
guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection 
procedures (epidural or subarachnoid) (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 services. Our reviewer found for code 64636, the 
documentation submitted was reviewed and does not meet criteria. The procedure report documents, "The 
injection site was prepped in the usual sterile fashion prior to the injection. The skin and subcutaneous tissues 
were anesthetized with 2 percent lidocaine, 0.5cc at each level...The medial brances were identified under 
fluoroscopy.  Using sterile techniques and under fluoroscopic guidance, the 22-guage 10 mm active tip 
radiofrequency needles were advanced to the junction of the superior articular process and the adjacent 
transverse process at each level... Then I cc Dexamethasone 10mg/cc mixed with 3cc of 0.5% Marcaine at each 
of the levels after negative aspiration for blood". The provider reported additional facet joint; however, one 
joint was treated in this case. An additional joint cannot be verified. 
 
For code 77003, the documentation submitted was reviewed and does not meet criteria. The procedure report 
does not support additional facet joints, which the add-on code CPT 64636 cannot be verified. Therefore, the 
radiology service would be included in the primary procedure, and not reported separately. 
 
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 the destruction by neurolytic agent (64636-RT) and the fluoroscopic guidance and localization 
(77003) provided on July 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on January 31, 
2023. 
 
You asked the Plan to pay for an office visit and related services. You say that the services were medically 
necessary. 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 an office visit and 
related services provided on January 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 22, 2022, billed with 
codes 81225, 81227, 81230, 81231, 81232, 81291, 81306, 81328, 81355, 0031U, 0032U, and 0033U. 
 
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 
May 22, 2022, billed with codes 81225, 81227, 81230, 81231, 81232, 81291, 81306, 81328, 81355, 0031U, 
0032U, and 0033U.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on 
December 02, 2022, to December 13, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with 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 $1,375 
copayment for inpatient hospital care. 
 
You have been asked to pay a $1,375 copayment for inpatient hospital care. This item/service falls within the 
inpatient hospital care 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 inpatient 
hospital care provided on December 02, 2022, to December 13, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on December 06, 2022. 
 
You asked the Plan to pay for psychotherapy. You say that the services should be covered. 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 psychotherapy provided 
on December 06, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided on July 19, 2022. 
 
You asked the Plan to pay for outpatient services. You say that you say that the assisted living facility was 
responsible for authorization. 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 outpatient services 
provided on July 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on January 17, 
2023. 
 
You asked the Plan to pay for an office visit and related services. You say that this service is supported in the 
records. 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 an office visit and 
related services provided on January 17, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97140 billed for date of service September 
30, 2022. 
 You asked the Plan to pay for procedure code 97140. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 97140 is bundled into payment for code 97760. 
 
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 97140 
is a column II code to column I code 97760. 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 97140 billed for date of service September 30, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the prostate surgery provided on January 
16, 2023, to January 17, 2023. 
 
You asked the Plan to waive the coinsurance for the prostate surgery. You say that you were told this facility 
was in-network. 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 40% 
coinsurance for out-of-network outpatient surgery. 
 
You have been asked to pay 40% coinsurance for the prostate surgery. This item/service falls within the out-of-
network outpatient surgery 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 surgery was provided at an out-of-network facility. The total you 
owe is $1,789.46 ($4,473.65 allowed amount  x 40% coinsurance = $1,789.46). Therefore, we decided that the 
Plan does not have to waive the coinsurance for the prostate surgery provided on January 16, 2023, to January 
17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Know Error DNA Specimen Provenance Assay (DSPA) 
rendered on July 20, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the testing is not covered. 
 
The Plan must follow Medicare rules. The rules say that the know error DNA Specimen Provenance Assay is 
a statutorily excluded test. 
 
We looked at the file and Medicare rules. The test at issue is the Know Error DNA Specimen Provenance 
Assay. This test is excluded from coverage by Medicare. Therefore, we decided that the Plan does not have to 
pay for the Know Error DNA Specimen Provenance Assay (DSPA) rendered on July 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cataract surgery provided on December 
14, 2022. 
 
You asked the Plan to waive the copayment for the cataract surgery. You say that you never had to pay for this 
type of surgical procedure before. 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 $50 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $50 copayment for the cataract surgery. This item/service falls within the outpatient surgery, including services provided at hospital outpatient facilities 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 cataract surgery provided on December 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue additional reimbursement for the gym membership (S9970) 
purchased on February 17, 2022. 
 
You asked the Plan to issue additional reimbursement for this service. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says you have 
exhausted the allowable benefit for this service.  
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.   
  
 
The Plans rules for coverage of gym benefits have not been met because you have exhausted the allowable 
benefit for this service. Specifically, the wellness allowance benefit offers reimbursement of $150 per calendar 
year towards your cost for membership in a qualified health club or fitness facility. The Plan previously issued 
reimbursement to you on March 11, 2022 and February 10, 2023 for the total amount of $150 ($49 + $101) for 
the gym membership purchased. Therefore, you have exhausted the allowable benefit for this service. 
Therefore, we decided that the Plan does not have to issue additional reimbursement for the gym membership 
(S9970) purchased on February 17, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown (D2751) for tooth #9. 
 
You asked the Plan to pre-approve the dental service. You say that the requested crown is medically necessary. 
The Plan denied your request. The Plan says that the tooth has a lot of tooth missing from the cavity and cannot 
be fixed. 
 
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 the dental 
service 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 dental service. Our reviewer says 
that the requested dental service meets the criteria for coverage. Our physician reviewer found the 
documentation indicates that tooth #9 has a fracture involving the mesial incisal angle and a distal restoration. 
A crown restoration is medically reasonable and necessary to provide adequate function and to prevent further 
fracture. 
 
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 dental service have been met. Therefore, we decided that the Plan has to 
pre-approve a crown (D2751) for tooth #9.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve geniculate artery embolization (37242). 
 
You asked the Plan to pre-approve geniculate artery embolization (37242). You say that the requested 
geniculate artery embolization (37242) to treat knee arthritis is medically necessary.  The Plan denied your 
request. The Plan says the requested geniculate artery embolization (37242) to treat knee arthritis is not 
medically necessary.  
 
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 geniculate artery embolization (37242). 
Our reviewer says that the requested geniculate artery embolization (37242) to treat knee arthritis is not 
medically necessary.  Our physician reviewer found the enrollee was being treated for unilateral primary 
osteoarthritis of the left knee. He presented with bilateral knee pain. The exam revealed bilateral knee lateral and medial joint line tenderness is noted. There is right knee small effusion. There is moderate left knee 
effusion. There is decreased range of motion. 
 
However, there is limited published, large-scale, long-term peer-reviewed literature that shows this request to 
be an effective and/or safe treatment for the noted pathology. While the studies are noted to be promising, 
further studies/research is needed to corroborate that geniculate artery embolization is as good as or better than 
standard treatments for knee osteoarthritis. No compelling rationale is presented, or extenuating circumstances 
noted to support the medical necessity of this request as an exception. Therefore, the requested geniculate 
artery embolization (37242), 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 geniculate artery embolization (37242) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve geniculate artery embolization (37242).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drugs or medicaments dispensed in the office for home use 
and the localized delivery of antimicrobial agents (D4381, D9630) provided on September 9, 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 the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for drugs or 
medicaments dispensed in the office for home use and the localized delivery of antimicrobial agents (D4381, 
D9630) provided on September 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 12, 2022. 
 
You asked the Plan to pay for laboratory services. You say that the services should be covered. 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 laboratory services 
provided on August 12, 2022.