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

 
We decided that the Plan does not have to pay for the lab testing services provided on September 20, 2021. 
 
You asked the Plan to pay for the lab services. You say that the testing was medically necessary. 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 the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for the lab testing services provided on 
September 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 billed for date of service September 2, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed code 
cannot be 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 J3490 is unclassified drugs. We find that CPT code J3490 
was billed to identify drug morphine sulfate. There is a more appropriate code available to describe the services 
provided.  
 Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code J3490 billed for date of 
service September 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on November 
29, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the enrollee's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
We looked at the file and the rules. The claim shows the items at issue were provided at an ambulatory surgical 
center. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, 
neither Medicare nor the Plan covers equipment for use outside the home.  Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the pneumatic compression device provided on November 29, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99283) provided on July 2, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in 
the global surgery payment. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery..  
 
We looked at the file and Medicare rules. Payment for the requested services (99283) is included in the global 
surgery payment for the procedure (10060) provided on the same date of service. 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 services (99283) provided on July 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (K0820). 
 
You asked the Plan to pre-approve a power wheelchair. You say that it is imperative that the enrollee receives a 
power wheelchair. The Plan denied your request. The Plan says that the requested power wheelchair is not 
medically necessary. 
 
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 power wheelchair. Our reviewer says 
that the coverage criteria has not been met. Our physician reviewer found that the enrollee is neurologically 
intact and has limited endurance due to his medical conditions. The enrollee does not require power tilt or 
power tilt/recline. The enrollee also does not require alternative methods of controlling the power wheelchair. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Group 2 power wheelchair (K0820).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing panel billed for date of service June 29, 2022. 
 
You asked the Plan to pay for the billed services. You say that the test was to determine the cause of the 
enrollee's symptoms. The Plan denied your request. The Plan says one code must be submitted for the panel. 
 
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 the urinary tract infection panel was not billed with a single code as required. Based on this 
information, we decided that Medicare rules for coverage of the billed services have not been met. Therefore, 
we decided that the Plan does not have to pay for the lab testing panel billed for date of service June 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited reconsideration for 
the denial of an IRF admission. The Plan denied your request. The Plan says the IRF services requested do not 
meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitative care. While the 
enrollee may benefit from physical and occupational therapy, the enrollee's rehabilitation needs can be 
provided in a lower intensity and alternate setting such as in a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI).  
You asked the Plan to pre-approve SSBCI benefits. The Plan denied your request. The Plan says the criteria for 
eligibility have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cone beam CT capture and interpretation with field of 
view of both jaws; with or without cranium (D0367), surgical placement of implant body: endosteal implant 
(D6010), deep sedation/general anesthesia  first 15 minutes (D9222), each subsequent 15 minute increment 
(D9223), and unspecified implant procedure, by report (D6199). 
 
You asked the Plan to pre-approve the dental services represented by codes D0367, D6010, D9222, D9223, and 
D6199. You say that you a requesting a fast appeal in the matter of the denial of dental services to work needed 
in preparation of a long overdue replacement of a bridge and crown. The Plan denied your request. The Plan 
says these services are not covered by your dental plan. 
 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 
cone beam CT capture and interpretation with field of view of both jaws; with or without cranium (D0367), 
surgical placement of implant body: endosteal implant (D6010), deep sedation/general anesthesia  first 15 
minutes (D9222), each subsequent 15 minute increment (D9223), and unspecified implant procedure, by report 
(D6199).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the vertiflex device placement surgery (22869, 22870, 
C1821). 
 
You asked the Plan to pre-approve the vertiflex device placement surgery. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the vertiflex device is considered experimental. 
 
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 vertiflex device placement surgery. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the vertiflex device is considered 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 the vertiflex device placement surgery have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the vertiflex device placement surgery (22869, 22870, 
C1821).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on November 16, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services are separately 
payable. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
November 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) and core buildup (D2950) for tooth 
#18. 
 
You asked the Plan to pre-approve crown and core buildup. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee has poor prognosis. It is recommended to extract the tooth. 
 
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 crown and 
core buildup 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 crown and core buildup. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found tooth #18 is seen on the provided x-ray as having 80% missing bone around the two roots.  A tooth should have at least 50% remaining 
bone to allow for proper support and function over time.  Where a tooth has more than 50% bone loss, 
particularly in the furcation between the roots as in this case, the prognosis is poor.  Neither the core buildup or 
crown would be indicated on a tooth with such a prognosis. 
 
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 crown and core buildup have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a crown (D2740) and core buildup (D2950) for tooth #18.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a 2D oral/facial photographic image obtained intra-orally or 
extra-orally (D0350), and unspecified diagnostic procedure, by report (D0999) provided on December 20, 
2022. 
 
You asked the Plan to pay for the dental services represented by codes D0350 and D0999. The Plan denied 
your request. The Plan says these services are not covered under the benefit package. 
 
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 2D 
oral/facial photographic image obtained intra-orally or extra-orally (D0350), and unspecified diagnostic 
procedure, by report (D0999) provided on December 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns (D6750, D6752 and D6792) and pontics 
(D6240, D6210). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says you already received the allowed approval on the appealed claim. 
 
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. Therefore, we decided that the Plan does 
not have to pre-approve retainer crowns (D6750, D6752 and D6792) and pontics (D6240, D6210).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for resin-based composite (D2391) and gingivectomy or 
gingivoplasty (D4212) provided on December 13, 2022. 
 
You asked the Plan to pay more for the dental services. You say that this should be covered in full. The Plan 
denied your request. The Plan says you are responsible for any charged amount above the Plans cost-sharing 
amount when your services are received from an out-of-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. 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for resin-based composite (D2391) and 
gingivectomy or gingivoplasty (D4212) provided on December 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam provided by Jeffrey A. Jones O.D on December 
7, 2022. 
 
You asked the Plan to pay for the eye exam. You say that you are appealing whether the provider is an 
approved eye exam provider. The Plan denied your request. The Plan says the provider is not certified with 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The service at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the eye 
exam provided by Jeffrey A. Jones O.D on December 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item is not medically necessary. 
 
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. 
 
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. Our reviewer says 
that the member does not need this item. Our physician reviewer found the patient does not have COPD, and does not have neuromuscular disease or thoracic restrictive disease. There is no arterial blood gas (ABG) done 
while stable to document chronic carbon dioxide (CO2) retention. If that is present, the patient may benefit 
from CPAP or BiPAP during sleep.  Medicare does not cover a home ventilator when used in the treatment of 
obesity hypoventilation syndrome, or when used at settings that can be provided with BiPAP. 
 
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 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture  maxillary (D5110), and complete 
denture  mandibular (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 3, 2020. 
Therefore, we decided that the Plan does not have to pre-approve complete denture  maxillary (D5110), and 
complete denture  mandibular (D5120).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 24 additional physical therapy visits. 
 
You asked the Plan to pre-approve the physical therapy visits. You say that you fear that further regression will 
lead to a fall which will require more aggressive treatment to repair the damage due to a possible injury. The 
Plan denied your request. The Plan says 24 additional physical therapy visits are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that you have an effective home exercise program which has 
improved and maintained your strength. Continued strength training is a repetitive exercise and physical 
therapy will not address the persistence neurological impairment. Therefore, continued input from a skilled 
therapist is not medically 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 the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 24 additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upright walker with enclosed frame (E0144). 
 
You asked the Plan to pre-approve an upright walker with enclosed frame. You say that this is medically 
necessary. The Plan denied your request. The Plan says there is no documentation that a standard walker will 
not meet your needs. 
 
The Plan must follow Medicare rules. Medicare rules say that the medical necessity for a walker with an 
enclosed frame (E0144) has not been established. Therefore, if an enclosed frame walker is provided, it will be 
denied as not reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an upright walker with enclosed frame have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an upright walker with enclosed frame (E0144).