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

 
We decided that the Plan does not have to pay more for the retainer crown - porcelain/ceramic (D6740) x1 
provided on March 2, 2023, to April 19, 2023. 

You asked the Plan to pay more for the dental services. You say that your insurance should have covered all of 
the dental services you received. 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid $131 for date of service January 18, 2023, $1,697.20 for date of service March 2, 2023, 
$2,060.40 for date of service April 19, 2023, and $111.40 for date of service April 24, 2023 ($131 + $1,697.20 
+ $2,060.40 + $111.40 = $4,000). Therefore, your benefit was exhausted. Therefore, we decided that the Plan 
does not have to pay more for the retainer crown - porcelain/ceramic (D6740) x1 provided on March 2, 2023, 
to April 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous left atrial appendage closure (LAAC) 
device (33340). 
 
You asked the Plan to pre-approve LAAC device. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that LAAC devices are covered when the device has 
received Food and Drug Administration (FDA) Premarket Approval (PMA) for that devices FDA-approved 
indication and meet all criteria. 
 
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 LAAC device. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found LAAC placement would not be 
considered reasonable or medically necessary in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LAAC device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous left atrial appendage closure (LAAC) device (33340).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
June 5, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service June 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete cancer panel provided on May 24, 2023. 
 
You asked the Plan to pay for the complete cancer panel. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not a covered benefit.  
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The complete cancer panel test at issue in this appeal was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for the complete cancer panel provided on May 24, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code G0481 provided on April 10, 2023. 
 
You asked the Plan to pay for procedure code G0481. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services 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 G0481 is Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to 
gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, 
eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 8-14 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0481 is supported in the medical record. Specifically, the records show that 11 drug 
classes were tested, including Alcohol biomarkers, Amphetamines, Buprenorphine, Fentanyl, Heroin 
metabolite, Methadone, Methylenedioxyamphetamines, Opiates, Opioids and opiate analogs, Oxycodone, and 
Tramadol. Based on this information, we decided that Medicare rules for coverage of procedure code G0481 
have been met. Therefore, we decided that the Plan has to pay for procedure code G0481 provided on April 10, 
2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN) 
in the home health or hospice setting. 
 You asked the Plan to pre-approve home health services. You say that direct skilled nursing services is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the services are not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found provided 
records do not document any acute or unstable medical conditions or changes in medication or treatment which 
would necessitate any further skilled nursing visits beyond what have already been 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve direct skilled nursing services of a registered nurse (RN) in the home health or 
hospice setting.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95941 billed for date of service March 2, 
2023. 
 
You asked the Plan to pay for procedure code 95941. You say that you would like the Plan to reconsider their 
denial of payment. 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 95941 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 95941 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 95941 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 95941 billed for date of service March 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for polycarbonate lenses (V2784) provided on January 12, 2023. 
 
You asked the Plan to pay for polycarbonate lenses (V2784). You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says polycarbonate lenses (V2784) are not covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one pair of standard lenses and frames. Lens enhancements are excluded from this 
benefit. 
 
We looked at the file and the Plan's rules. The Plan rules say that they cover one pair of standard lenses and 
frames every year. Polycarbonate lenses are excluded from this benefit. Based on this information, we decided 
that the Plan's rules for coverage of polycarbonate lenses (V2784) have not been met. Therefore, we decided 
that the Plan does not have to pay for polycarbonate lenses (V2784) provided on January 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87491, 87563, 87640, 87653, and 
87798 provided on May 20, 2023. 
 
You asked the Plan to pay for procedure codes 87481, 87491, 87563, 87640, 87653, and 87798. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 87481, 87491, 87563, 87640, 87653, and 87798 are not supported in the medical 
record. Specifically, a panel was performed and there is a more appropriate singular code for the services. 
Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 87481, 87491, 87563, 87640, 
87653, and 87798 provided on May 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fixed partial denture sectioning (D9120) and interim 
crown (D2799 x3). 
 
You asked the Plan to pre-approve fixed partial denture sectioning and interim crown. You say that the services 
are necessary. The Plan denied your request. The Plan says the services are not covered. 
 
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 fixed 
partial denture sectioning (D9120) and interim crown (D2799 x3).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 You asked the Plan to pre-approve Evenity. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Evenity. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has age related osteoporosis without osteoporotic fracture. The documentation does 
not support that the enrollee has tried and failed zoledronic acid or Prolia. The documentation does not support 
that zoledronic acid or Prolia would likely be less effective and/or likely have adverse effects for the enrollee. 
Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options (tilt/recline, leg rest elevator, seat elevator) and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options. You say that your 
current power wheelchair is no longer repairable the equipment is no longer in circulation. You say that you 
have fallen 12 times in the past two months while attempting to walk in your home. You also say that without 
your wheelchair you are very limited on daily living activities The Plan denied your request. The Plan says the 
records do not show a medical need for multiple power options included in the requested Group 3 power 
wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 Group 3 power wheelchair with 
multiple power options. Our reviewer says that the requested Group 3 power wheelchair is not medically 
necessary in this case. Our physician reviewer found that although you have a Group 3 neurological diagnosis, 
you have no need for a ventilator or for power tilt and recline. The documentation does not support that you are 
at high risk for development of a pressure ulcer, utilize intermittent catheterization for bladder management, or 
need a power seating system to manage increased tone or spasticity. You have no history of prior pressure ulcer 
with prior wheelchair use and no documentation of flap surgery. You have no history of ventilator use. The 
request for power and tilt exceeds your medical needs. Also, the requested accessories are not medically 
necessary as you can control any power options through their own switches. As such, the Group 3 Power 
Wheelchair with multiple power options is not reasonable and necessary; none of the requested accessories can 
be covered. 
 
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 Group 3 power wheelchair with multiple power options have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple 
power options (tilt/recline, leg rest elevator, seat elevator) and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics.  
 
You asked the Plan to pay for foot orthotics. You say that you have pain due to your foot pain. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone graft at time of implant placement (D6104) provided 
on April 18, 2023. 
 
You asked the Plan to pay for D6104. You say that you needed this dental work. The Plan denied your request. 
The Plan says the denied dental 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 pay for a bone 
graft at time of implant placement (D6104) provided on April 18, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergent ambulance services (A0425, A0428) to 
be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve non-emergent ambulance services. You say that the enrollee has dialysis 
appointments, and she needs the ambulance to take her. The Plan denied your request. The Plan says  the 
service requested is available in network. 
 
 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. Please note that the Plan has approved transition of care non-
emergent ambulance services with the OON provider through November 11, 2023. Ongoing ambulance 
services after November 11, 2023, will need to be provided by an in-network provider. Therefore, we decided 
that the Plan does not have to pre-approve non-emergent ambulance services (A0425, A0428) to be provided 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 81218 and 81209. We 
decided that the Plan does not have to pay for the services described by procedure code(s) 81272, 81314, and 
81345.  
 
You asked the Plan to pay for procedure codes 81218, 81209, 81272, 81314, and 81345 provided on April 6, 
2023. You say that you would like the Plan to reconsider their denial of payment. The Plan says that the 
services are not covered as billed. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 81218 and 81209.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 81218 and 81209.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
81272, 81314, and 81345. 
 
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 81272, 81314, and 
81345 have not been met. Therefore, we decided that the Plan does not have to pay for the services described 
by procedure code(s) 81272, 81314, and 81345. 
 
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.