Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 sensor and receiver. 
 
You asked the Plan to pre-approve the Dexcom G7 sensor and receiver. The Plan denied your request. The Plan 
says the rules for a Dexcom G7 sensor and receiver have not been met. Documentation that you have had 
adequate therapeutic trial and failure on an Abbott product must be provided for the requested item to be 
considered for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans may limit coverage to certain brands of 
products and this plan only covers Abbott and Lifescan CGMs. 
 
 We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for a CGM. Based on this information, we decided that Medicare rules for coverage of the Dexcom G7 sensor 
and receiver have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom 
G7 sensor and receiver.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 6, 2023, to 
August 4, 2023. 
 
You asked the Plan to pay for the home health services as billed. 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 follows Medicare rules. The rules say that certain data elements are required. 
 
We looked at the claim submitted, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, we find that 
the first Q code line and first G code line were not billed with the same revenue code. Therefore, we decided 
that the Plan does not have to pay for the home health services provided from July 6, 2023, to August 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a retainer crown (D6750) provided on August 7, 2023. 
 
You asked the Plan to pay more 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 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 August 7, 2023. 
Therefore, we decided that the Plan does not have to pay more for a retainer crown (D6750) provided on 
August 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical extractions and core buildup services (D2950, 
D7210) provided on August 3, 2023, to August 4, 2023. 
 
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 surgical 
extractions and core buildup services (D2950, D7210) provided on August 3, 2023, to August 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an amalgam (D2160) provided on August 4, 2023. 
 
You asked the Plan to pay more 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 cost-sharing applied correctly based 
on the services provided. 
 
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 a 20% coinsurance for an amalgam. This item/service falls within the Class 2 
Dental 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 pay more for an amalgam (D2160) provided on 
August 4, 2023.
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 
July 31, 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 July 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction (D7210) for tooth #6 and #27, a bone 
replacement graft (D7953) for tooth #6 and #27, deep sedation (D9222 and D9223), and a consultation 
(D9310) provided on August 4, 2023. 
 
You asked the Plan to pay for the dental services. You say that the extractions were necessary so you could get 
your dentures. The Plan denied your request. The Plan says your annual maximum benefit for the year has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid $121 for dental services on June 3, 2023. On July 11, 2023, the Plan paid $1,181 for dental 
services. On July 25, 2023, the Plan paid $883 for dental services. On July 27, 2023, the Plan paid $51 for 
dental services. On August 4, 2023, the Plan paid $88 for dental services. On August 28, 2023, which was 
processed and paid prior to the date of service of August 4, 2023, the Plan paid $1,676 for dental services. For 
the year of 2023 the Plan paid $4,000 ($121 paid + $1,181 paid + $883 paid + $51 paid + $88 paid + $1,676 
paid); therefore, your annual maximum benefit for the year of 2023 was exhausted on the date of service of 
August 4, 2023. Therefore, we decided that the Plan does not have to pay for an extraction (D7210) for tooth 
#6 and #27, a bone replacement graft (D7953) for tooth #6 and #27, deep sedation (D9222 and D9223), and a 
consultation (D9310) provided on August 4, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on May 
12, 2023. 
 
You asked the Plan to pay for the ED services. You say that you are requesting the claim be reviewed and 
reprocessed for payment. The Plan denied your request. The Plan says Medicare payment cannot be made to 
this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
 We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on May 12, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has tried and failed 
conservative treatment for more than six months and has been in pain for the same amount of time. The Plan 
denied your request. The Plan says the requested procedure has not been proven to help the enrollee's 
diagnosis. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the documentation lacks detailed findings that the spinal vertebral bodies are the 
primary generators of the enrollees chronic persistent pain. There are multiple plausible pathologic sources of 
significant pain generation. Therefore, formal surgical ablation of the basivertebral nerves is not medically 
necessary at this time. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone marrow aspiration. 
 
You asked the Plan to pre-approve a bone marrow aspiration. You say that the enrollee requires the requested 
procedure. The Plan denied your request. The Plan says the requested information is not proven to be 
reasonable and 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 a bone marrow aspiration. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no specific indication provided to support the request for bone marrow 
aspirate for the approved surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to 
support the use of bone marrow aspirate for this enrollees medical condition. No compelling rationale is 
presented, or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the requested bone marrow aspiration 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 bone marrow aspiration have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a bone marrow aspiration.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ear molds (V5264) provided on June 6, 2023. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not a covered benefit. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that ear molds are not a 
covered benefit.   
 
Therefore, we decided that the Plan does not have to pay for the ear molds (V5264) provided on June 6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Superion Vertiflex procedure. 
 
You asked the Plan to pre-approve the Superion Vertiflex procedure. You say that you have chronic pain, and 
your providers are recommending this procedure over other surgical options. This procedure could improve 
your quality of life and allow you to be more active which would help you maintain your strength. The Plan 
denied your request. The Plan says experimental and investigational procedures are not covered. 
 
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 Superion Vertiflex procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the Superion Vertiflex procedure is considered 
experimental/investigational and is not medically necessary for the treatment of chronic back 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 the Superion Vertiflex procedure have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the Superion Vertiflex procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lower partial denture (D5226) and to waive the coinsurance 
for a complete upper denture (D5110) provided on March 22, 2023, and May 3, 2023. 
 
You asked the Plan to pay for the dental services. You say that your book says that the dental services should 
be covered at 50% of the total cost. The Plan denied your request. The Plan says the proper cost share was 
applied for the complete upper denture. Also, the lower partial denture is not covered by the 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. 
 
  The total allowed amount for the complete upper denture (D5110) was $897 and the total coinsurance amount 
was $448.50 ($897 allowed x 50% coinsurance). 
 
You have been asked to pay a 50% coinsurance for the complete upper denture. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. The lower partial denture is not 
covered under the Plan's dental benefit. Therefore, we decided that the Plan does not have to pay for a lower 
partial denture (D5226) and to waive the coinsurance for a complete upper denture (D5110) provided on March 
22, 2023, and May 3, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial hospitalization program. 
 
You asked the Plan to pre-approve partial hospitalization program. You say that you are appealing this denial. 
The Plan denied your request. The Plan says you do not meet criteria for partial hospitalization. 
 
The Plan follows Medicare rules. Medicare rules state that a partial hospitalization program may be covered 
when deemed medically necessary for the enrollee.  
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 partial hospitalization program. Our 
reviewer says that you do not meet criteria for a partial hospitalization program. Our physician reviewer found 
you are not showing any dangerousness to self or others and have not been exhibiting severe psychological or 
psychiatric impairment requiring this level of care. You could be treated in a less restrictive setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of partial hospitalization program have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a partial hospitalization program.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. 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 must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. This enrollee may benefit from bilevel positive airway pressure (BiPAP) during sleep as an 
outpatient. The records do not show this has been tried and failed as an outpatient. The volume assurance mode 
can be provided with BiPAP, if necessary. Medicare does not cover a home ventilator 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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 85045, 87186, 87088, and P9603 billed for 
April 17, 2023. 
 
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 services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider for billed codes 85045, 87186, and 87088. Without 
a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been 
met. 
 
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 P9603 is travel allowance one way in connection with 
medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; 
prorated miles actually travelled. 
 
We find that CPT code P9603 is not supported in the medical record. Specifically, the records do not include a 
prorated miles traveled log in connection with medically necessary laboratory specimen collection drawn from 
a homebound or nursing home patient. 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 85045, 87186, 87088, and P9603 
billed for April 17, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve VIA disc at L3-4. 
 
You asked the Plan to pre-approve VIA disc at L3-4. 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 VIA disc at L3-4. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested VIA disc at L3-4 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 VIA disc at L3-4 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve VIA disc at L3-4.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81479 provided on July 6, 2023. 
 
You asked the Plan to pay for procedure code 81479. You say that you would like the Plan to reconsider their 
denial of payment. 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 procedure code 81479 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 81479 
provided on July 6, 2023.