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

 
We decided that the Plan does not have to pay for anesthesia services (64635, 64636, 99152, 99153, J2250, 
J7040) provided on January 17, 2023. 
 
You asked the Plan to pay for the anesthesia services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed service. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the anesthesia services have been met. 
No medical records were provided to support the billed service. The plan requested additional records and none 
were provided. Therefore, we decided that the Plan does not have to pay for anesthesia services (64635, 64636, 
99152, 99153, J2250, J7040) provided on January 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye examination (92014) provided on March 13, 
2023. 
 
You asked the Plan to pay for a medical eye examination (92014). You say that you have been a patient of this 
provider for years. 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 (92014) provided on March 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial lower denture (D5214). 
 
You asked the Plan to pre-approve the dental service. You say that you lost your previous denture and you need 
it replaced. 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 the date of service of March 14, 2023. 
Therefore, we decided that the Plan does not have to pre-approve a partial lower denture (D5214).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient diagnostic test provided on 
June 08, 2023. 
 
You asked the Plan to waive the copayment for an outpatient diagnostic test. 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 $50 
copayment for outpatient diagnostic test/Medicare-covered standard x-ray and ultrasound. 
 
You have been asked to pay a $50 copayment for an outpatient diagnostic test. This item/service falls within 
the outpatient diagnostic test/Medicare-covered standard x-ray and ultrasound 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 outpatient diagnostic test provided on June 08, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block (64624). 
 
You asked the Plan to pre-approve a genicular 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 a genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this procedure is considered experimental/investigational. It is the subject of ongoing 
clinical trials. Therefore, the request is deemed not medically reasonable and 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 a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block (64624).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the specialist office visit provided on 
March 17, 2023. 
 
You asked the Plan to reduce the copayment for the specialist office visit. You say that you would like the 
copayment lowered for this service. 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 $40 
copayment for specialist physician/practitioner services.  
You have been asked to pay a $40 copayment for the specialist office visit. This item/service falls within the 
specialist physician/practitioner 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 reduce the copayment 
for the specialist office visit provided on March 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Lite test strips. 
 
You asked the Plan to pre-approve the blood glucose test strips. You say that you are appealing the denied test 
strips. The Plan denied your request. The Plan says only the preferred brand products listed in the EOC are 
covered.  
  The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the blood glucose test strips. Therefore, we decided that the Plan does not have to pre-approve a Freestyle 
Lite test strips.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex device (22869). 
 
You asked the Plan to pre-approve a Vertiflex device. 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 a Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the vertiflex device is experimental. 
 
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 Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex device (22869).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs system (C2624, 33289). 
 
You asked the Plan to pre-approve a CardioMEMs system. 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 a CardioMEMs system. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and 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 a CardioMEMs system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMs system (C2624, 33289).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Lite test strips. 
 
You asked the Plan to pre-approve Freestyle Lite test strips. You say that the items are necessary. The Plan 
denied your request. The Plan says only the preferred brand products listed in the EOC are covered.  
 The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for Freestyle Lite test strips. Therefore, we decided that the Plan does not have to pre-approve Freestyle Lite 
test strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abutment supported porcelain/ceramic crown. 
 
You asked the Plan to pre-approve abutment supported porcelain/ceramic crown. You say that this is medically 
necessary. The Plan denied your request. The Plan says this is not a covered service. 
 
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 
abutment supported porcelain/ceramic crown.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057), an abutment 
supported porcelain/ceramic crown (D6058), and a porcelain/ceramic pontic (D6245). 
 
You asked the Plan to pre-approve a custom fabricated abutment (D6057), an abutment supported 
porcelain/ceramic crown (D6058), and a porcelain/ceramic pontic (D6245). You say that you have been 
disappointed to learn of the Plan's restrictions on dental coverage, especially since you are being told that an 
implant will give you the best outcome. The Plan denied your request. The Plan says according to your EOC, 
there is no coverage for these services. 
 
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 a 
custom fabricated abutment (D6057), an abutment supported porcelain/ceramic crown (D6058), and a 
porcelain/ceramic pontic (D6245).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L4 kyphoplasty (22514). 
 
You asked the Plan to pre-approve L4 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says medical necessity coverage criteria is not met as the pain is multifactorial with 
multilevel disc disease in the lumbar spine. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific criteria 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 pre-approve L4 kyphoplasty. Our reviewer says that 
the enrollee does not meet criteria for coverage. Our physician reviewer found detailed documentation is not 
evident regarding worsening pain. There is no indication of a progression of the body height loss, greater than 
25% vertebral body height loss, kyphotic deformity, or a severe impact on daily activities. Moreover, there is 
magnetic resonance imaging corroboration of other plausible causes of the pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L4 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L4 kyphoplasty (22514).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory tests (81218, 81209) provided on December 2, 
2022. 
 
You asked the Plan to pay for laboratory tests. You say that these services were necessary and are supported in 
the medical record. The Plan denied your request. The Plan says the claim for this molecular pathology testing 
did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of laboratory tests have 
not been met. Therefore, we decided that the Plan does not have to pay for laboratory tests (81218, 81209) 
provided on December 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PVA. 
 
You asked the Plan to pre-approve the PVA. You say that you are appealing the denial with supporting medical 
documentation. The Plan denied your request. The Plan says this procedure is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PVA is covered when the criteria listed in the 
Medicare rules section 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 pre-approve the PVA. Our reviewer says that the 
coverage criteria has not been met. Our physician reviewer found that the MRI does not show an acute fracture 
less than 12 weeks old. 
 
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 PVA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a PVA.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87640 billed for date of service February 27, 
2023. 
 
You asked the Plan to pay for procedure code 87640. You say that this service is supported in the medical 
record. The Plan denied your request. The Plan says this code is not supported for separate billing. 
 
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 87640 is a column II code to column I code 87641; however, 87640 
was billed with a modifier.  
 
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 procedure code 87640. Our reviewer says that this code is 
not supported for separate reporting or payment. Our reviewer found the laboratory report does not include 
documentation to support any rationale for billing both procedure codes on same date of service.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 87640 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87640 billed for date of service February 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown (D6752 x1) and a pontic (D6242 x1). 
 
You asked the Plan to pre-approve retainer crowns (D6752 x2) and pontics (D6242 x2). You say that the 
documentation says there is a $0 copay for bridges. You say the Plan has no right to represent a $0 copay and 
not provide that service. 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 your benefit for the requested item or service was exhausted when the Plan authorized one of the two 
requested retainer crowns and one of the two pontics. Therefore, we decided that the Plan does not have to pre-
approve an additonal retainer crown (D6752 x1) and an additional pontic (D6242 x1).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on November 22, 2022. 
 
You asked the Plan to pay for the lab services. You say that the documentation supports the claim. The Plan 
denied your request. The Plan says an incorrect place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
The file shows that a combined cardio hereditary and pharmacogenetics testing panel was provided. The claim 
was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory 
setting. The panel testing was not billed with a single code as required. We looked at the file and Medicare 
rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been 
met. Therefore, we decided that the Plan does not have to pay for the lab services provided on November 22, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty. 
 
You asked the Plan to pre-approve a kyphoplasty. You say that this procedure is medically necessary. The Plan 
denied your request. The Plan says a kyphoplasty is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a kyphoplasty is covered when the criteria listed in 
the Medicare rules section 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 pre-approve a kyphoplasty. Our reviewer says that 
the coverage criteria has not been met. Our physician reviewer found that there is no trial and failure of bracing 
for fracture care. 
 
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 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a kyphoplasty.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six (6) units of ultrasonic guidance for needle placement 
(76942). 
 
You asked the Plan to pre-approve ultrasonic guidance for a biopsy. You say that the needle placement is 
medically necessary. The Plan denied your request. The Plan says the needle placement does not meet criteria 
for coverage. 
 
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 ultrasonic guidance for a biopsy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has a history of end stage renal disease on dialysis and was 
referred for an echo guidance for a biopsy. The documentation does not support that echo guidance for a biopsy 
is medically necessary or that it meets the medical necessity criteria outlined. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultrasonic guidance for a biopsy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve six (6) units of ultrasonic guidance for needle placement (76942).