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

 
We decided that the Plan does not have to pay for drug testing services (procedure code 80307 and G0482) 
rendered on November 9, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes remain 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 the denied codes is: 
 
CPT 80307: 
 
Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), 
chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, 
DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when 
performed, per date of service 
 
Healthcare Common Procedure Coding System (HCPCS) G0482: 
 
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; 15-21 drug class(es), including metabolite(s) if performed 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that no provider records or laboratory 
reports are identified for review.  As such, there is no evidence that the billed testing was medically necessary 
or provided. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing services (procedure code 80307 and G0482) rendered on November 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a kyphoplasty (22513).

You asked the Plan to pre-approve the kyphoplasty. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says this procedure is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that PVA (percutaneous vertebroplasty (PVP) or kyphoplasty (PKP) is covered in patients with osteoporotic VCF acute or subacute osteoporotic vertebral compression fracture (VCF), based on symptom onset, and documented by advanced imaging.

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 kyphoplasty. Our reviewer says that the request for a kyphoplasty is not medically necessary. Our physician reviewer found there is no detailed documentation indicating which level is being requested. Though the provider indicates T12, there is no documentation to corroborate a T12 fracture that is amendable to kyphoplasty. The reviewer found there is imaging which corroborates other plausible causes of pain. Therefore, the reviewer found that the requested kyphoplasty for T12 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 the kyphoplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve a kyphoplasty (22513).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from August 7, 2023, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from August 7, 2023, forward. You say that the 
services are medically necessary. The Plan denied your request. The Plan says the services are not medically 
necessary.  

The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 inpatient psychiatric care from August 
7, 2023, forward have been met. There are no medical records within the casefile. Without the requested 
clinical information, we are unable to determine if the requested services are medically necessary. Therefore, 
we decided that the Plan does not have to pre-approve inpatient psychiatric care from August 7, 2023, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a REVO 2.04 BLUE power scooter (K0899).  
 
You asked the Plan to pre-approve the power scooter. You say that you tried this scooter but do not have 
enough financial resources to purchase one yourself.  The Plan denied your request. The Plan says the medical 
records included in this request do not establish medical necessity for the brand specific item requested.  
 
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 power scooter. Our physician 
reviewer found according to Medicare, the plans may specify brands and manufacturers as preferred and charge 
lower cost-sharing for the preferred brands or may limit the durable medical equipment (DME) to only those 
preferred brands and manufacturers as long as the enrollee retains access to all medically necessary items 
(including non-preferred brands). In this case, the documentation available for review does not indicate the 
brand-named device improves an individuals overall function or general health more than the other standard 
equipment or treatments provided by the Health Plan. 
 
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 power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a REVO 2.04 BLUE power scooter (K0899).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and a cleaning (D1110) 
provided on March 23, 2023. 
 
You asked the Plan to pay for the dental services. You say that the dental services should be covered under 
your dental plan, and you receive 2 cleaning annually. The Plan denied your request. The Plan says the denial 
of payment for these services is correct, because the periodic oral evaluation and the cleaning are 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. 
 
  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 periodic 
oral evaluation (D0120) and a cleaning (D1110) provided on March 23, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for routine supplies, coded A0398, billed for date of service 
March 5, 2023. 
 
You asked the Plan to pay for the billed supplies. You say that medical records were provided. The Plan denied 
your request. The Plan says the supplies are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance supplies are considered part of the 
general ambulance service and payment for them is included in the payment rate for the transport. Therefore, 
we decided that the Plan does not have to pay for routine supplies, coded A0398, billed for date of service 
March 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) and core buildup (D2950) provided by an 
out-of-network provider on February 28, 2023. 
 You asked the Plan to pay for the dental services. You say that you are appealing the denied dental services. 
The Plan denied your request. The Plan says the denial of payment for these services is correct, because the 
crown and core buildup are 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. 
 
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 crown 
(D2740) and core buildup (D2950) provided by an out-of-network provider on February 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation services (D4921) provided on March 29, 
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 gingival 
irrigation services (D4921) provided on March 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental fillings (D2391, D2331) provided on April 25, 
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 April 25, 2023. 
Therefore, we decided that the Plan does not have to pay more for dental fillings (D2391, D2331) provided on 
April 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown and core buildup services (D2740, D2950) provided 
on March 9, 2023, by an out-of-network (OON) provider.  
 
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 dental services were received from an out-of-
network provider and are not covered by your supplemental 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. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a crown and core buildup services (D2740, D2950) provided on March 9, 2023, by an out-of-
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an endosteal implant and bone graft procedure (D6010, 
D6104) provided on March 8, 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 and they would cause financial hardship. 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 an 
endosteal implant and bone graft procedure (D6010, D6104) provided on March 8, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown and core buildup for tooth #24 and an extraction with bone grafting for tooth #25.
 
You asked the Plan to pre-approve the requested dental services. You say that these services should be covered. The Plan denied your request. The Plan says that an appeal review was not performed as the time frame for doing so was missed.
 
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. The Plan covers the requested dental services when the services are medically necessary and reasonable.
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested dental services. Our reviewer says that the requested dental services are shown to be medically necessary. Our physician reviewer found the provided records in this case document necessity for a crown and build-up for tooth #24. Records also document necessity for an extraction and bone graft replacement for tooth #25. There is no indication that the requested services in this case are cosmetic or are otherwise excluded based on the plan documentation..  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the requested dental services have been met. Therefore, we decided that the Plan has to pre-approve a crown and core buildup for tooth #24 and an extraction with bone grafting for tooth #25.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ophthalmological services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve ophthalmological services. You say that you would like to see the requested provider. The Plan denied your request. The Plan says this 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. Therefore, we decided that the Plan does not have to pre-approve 
ophthalmological services to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for an amalgam and filling (D2140, D2391) 
provided on April 12, 2023. 
 
You asked the Plan to waive the cost-sharing for the dental services. You say that the services should be 
covered as you disagree with the charges. 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 50% coinsurance and $100 deductible for the dental services. This item/service 
falls within the 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 waive the cost-sharing for an 
amalgam and filling (D2140, D2391) provided on April 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete lower denture (D5120) provided on April 13, 
2023. 
 
You asked the Plan to pay for the dental service. You say that the provider did not submit the right code and the 
denture is for a complete denture and not a partial denture so it 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 the Plan paid for a partial lower denture (D5214) on February 2, 2023; therefore, the enrollees benefit 
for the requested item or service was exhausted on the date of service of February 2, 2023. Therefore, we 
decided that the Plan does not have to pay for a complete lower denture (D5120) provided on April 13, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76882 billed for date of service December 
31, 2022. 
 You asked the Plan to pay for procedure code 76882. You say that code 76882 should be paid as billed because 
it was not bundled with any other procedure code on the same date of service. The Plan denied your request. 
The Plan says payment for code 76882 is bundled into payment for code 93971. 
 
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 76882 
is a column II code to column I code 93971. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76882 billed for date of service December 31, 
2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee has a broken hip and an abscess 
developed after surgery needing wound core management requiring daily physician monitoring. The Plan 
denied your request. The Plan says that the enrollee's records do not show the need for skilled services daily 
nor that the services can be provided only on an inpatient basis. Services required can safely be received at a 
different setting, home with home health, in residential care, or home with close follow-up with physician. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the clinical documentation does support daily skilled services on an inpatient basis in 
a skilled nursing facility meets criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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.