Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve intra-articular facet joint spinal injections. 
 
You asked the Plan to pre-approve intra-articular facet joint spinal injections. You say that intra-articular facet 
joint spinal injections are medically necessary. The Plan denied your request. The Plan says that the requested 
facet joint injections do not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 intra-articular facet joint spinal 
injections. Our reviewer says that the requested intra-articular facet joint spinal injections are considered 
medically necessary in this case. Our physician reviewer found the enrollee has chronic axial low back pain. The enrollee takes Sertraline for pain. In June 2022 the enrollee had bilateral intra-articular L4-L5 and L5-S1 
facet injection. This provided sustained pain relief for three months. On February 21, 2023, the enrollee had 
bilateral intra-articular L2-L3 and L3-L4 intra-articular facet injections but had 75% pain relief. The request is 
to repeat the L4-L5 and L5-S1 injections. The L4-L5, L5-S1 set of injections met the criteria for successful 
facet injection. The request to repeat the injection meets the criteria and are 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 intra-articular facet joint spinal injections have been met. Therefore, we decided 
that the Plan has to pre-approve intra-articular facet joint spinal injections.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift feature, expandable controller, harness 
upgrade, electronic connection, and bag hooks. 
 
You asked the Plan to pre-approve the seat lift feature, upgraded electronics, and bag hooks. You say that the 
requested Group 3 power wheelchair and accessories are medically necessary for the enrollee's medical, 
mobility, and functional needs. The Plan denied your request. The Plan says a seat elevator and bag hooks do 
not serve a primary medical purpose and are statutorily non-covered. The Plan also says that the enrollee's 
upper limb strength and function are adequate to be able to control the power options using their own switches 
which are included in the allowance of these power options. 
 
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 seat lift feature, upgraded 
electronics, and bag hooks. Our reviewer says that the upgraded electronics are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the provided records document that the 
enrollee has 3-/5 bilateral upper extremity strength and is independent with feeding and dressing thus indicating 
she has adequate upper extremity strength and function to operate the wheelchair's power options with their 
own switches. Therefore, the reviewer found that the requested upgraded electronics are 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 seat lift feature, upgraded electronics, and bag hooks have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a seat lift feature, expandable controller, 
harness upgrade, electronic connection, and bag hooks.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0245U billed for date of service February 22, 
2022. 
 
You asked the Plan to pay for procedure code 0245U. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 0245U is bundled into payment for code 0018U. 
 
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 0245U 
is a column II code to column I code 0018U. 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 0245U billed for date of service February 22, 
2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for the drug injection provided on November 4, 2022 
 
You asked the Plan to waive the coinsurance for the drug injection. You say that you received an approval 
before receiving these services. The Plan denied your request. The Plan says that this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay 20% coinsurance for in-network Medicare Part B drugs.  
 
You have been asked to pay 20% coinsurance for the drug injection. According to Medicare, the injection 
(code J0702) is considered a packaged code and is not separately payable. This code is also excluded from the 
physicians free schedule. Therefore, we decided that the Plan has to waive the coinsurance for the drug 
injection provided on November 4, 2022  
 
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: Surgery
Decision: Unfavorable

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

 
We decided that the Plan does not have to pay for dental services provided from May 4, 2021, to January 2, 
2023. 
 
You asked the Plan to pay 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 claim denied correctly as it was received 
untimely. Coverage for the dental services received on January 2, 2023 also denied correctly as you were not 
enrolled in the Plan at this time. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
Your complaint is not a valid appeal for medical coverage. You were not enrolled in the Plan on January 2, 
2023. 
 
The record shows that a claim for the dental services was not filed until January 14, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for dental services provided from May 4, 2021, to January 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the single vision lenses (V2100) provided on January 
12, 2023, by an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the single vision lenses. You say that you have a special need for glasses 
that cannot be rendered by the Plan-approved vision vendor. You also say that you were only reimbursed $35 
instead of the $175 that you paid. The Plan denied your request. The Plan says you were paid the Plan's share 
of $35.80 correctly, and no adjustment on the claim is needed. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers a 20% coinsurance for OON routine vision care. 
 
 
 
 We looked at the file and the Plan's rules. The record shows that the total cost you paid was $179.00. You are 
responsible for 80% of the total ($143.20), and the Plan has reimbursed you their 20% share ($35.80). Based on 
this information, we decided that the Plan's rules for coverage of the single vision lenses have not been met. 
Therefore, we decided that the Plan does not have to pay more for the single vision lenses (V2100) provided on 
January 12, 2023, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on December 30, 
2022, to January 03, 2023. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you were never in the ICU 
and if you were, it shouldn't be this much. 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 $175 
copayment for each day for days 1 - 7 per admission for inpatient hospital stay. There were four days. 4 x $175 
= $700. Therefore, results in the total cost sharing amount $700. 
 
You have been asked to pay a $175 copayment per day for inpatient hospital stay. This item/service falls within 
the inpatient hospital care 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 inpatient 
hospital stay on December 30, 2022, to January 03, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutment  includes placement 
(D6057) and abutment supported porcelain/ceramic crown (D6058) Tooth #20, 29, 30. 
 
You asked the Plan to pre-approve the dental services. You say that you need the requested service due to pain 
and not being able to eat properly. 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. This benefit includes the 
requested custom fabricated abutment  includes placement and abutment supported porcelain/ceramic crown 
(D6058) but is limited up to two implants covered per year, or up to four edentulous patients, covered one per 
tooth per life. Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you have been pre-approved for D6057 and D6058 Tooth #3, 19. Therefore, these benefits have been 
exhausted as of the pre-approval date March 17, 2023. Therefore, we decided that the Plan does not have to 
pre-approve custom fabricated abutment  includes placement (D6057) and abutment supported 
porcelain/ceramic crown (D6058) Tooth #20, 29, 30.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88377 and 88368 billed for date of service 
December 19, 2022. 
 
You asked the Plan to pay for procedure code 88377 and 88368. You say that the services were billed based on 
medical necessity. The Plan denied your request. The Plan says payment for codes 88377 and 88368 are 
bundled into payment for other services. 
 
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 codes 88377 and 88368 are a column II code to column I code 81270. The 
medical records do not show that the codes billed with the -59 modifier were a distinct procedural service. A 
modifier should not be appended to a code solely to bypass an 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 
88377 and 88368 billed for date of service December 19, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Oncotype DX AR-V7 Nucleus Detect genetic testing provided on 
July 1, 2022, billed with code 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that the procedure code is not payable. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was billed with a single panel code as 
required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have been met. Therefore, we decided that the Plan has to pay for the Oncotype DX AR-V7 Nucleus Detect 
genetic testing provided on July 1, 2022, billed with code 81479.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee is medically stable and no longer needs 
physician oversight, but they still need daily physical and occupational therapy in order to regain their 
independence. The Plan denied your request. The Plan says the enrollee has completed their intensive course of 
care at the inpatient rehab facility and intermittent therapy can safely be received at a different setting, such as 
home with home health or outpatient therapy in residential care. 
 
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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the clinical documentation shows that the enrollee has had a functional and clinical 
status change and would be expected to require continued assessment by skilled nursing and skilled therapy. 
Clinical documentation shows that all inpatient therapy goals have been met, and no specific recommendation 
given for frequency of ongoing skilled nursing provided. Clinical documentation does not show that the 
enrollee requires daily skilled services. The clinical documentation does not show that the enrollee requires 
daily skilled services on an inpatient basis 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on January 16, 2023. 
 
You asked the Plan to pay for the medication. You say that you were coming out of anesthesia and do not 
remember taking any medications. The Plan denied your request. The Plan says the medication is not covered 
as a medical benefit under the Plan. 
 
  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
on January 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Solid Tumor Profile Plus testing provided on August 24, 
2021. 
 
You asked the Plan to pay for the Solid Tumor Profile Plus testing. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of this 
testing. 
 
The Plan must follow Medicare rules. Medicare rules say that next generation sequencing (NGS) is covered for 
patients with advanced stage III or IV cancer. 
 
We looked at the file and Medicare rules. The file shows that the enrollee did not have a cancer diagnosis. 
Based on this information, we decided that Medicare rules for coverage of the Solid Tumor Profile Plus testing have not been met. Therefore, we decided that the Plan does not have to pay for the Solid Tumor Profile Plus 
testing provided on August 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service December 6, 2022. 
 
You asked the Plan to pay for the billed services. You say that the billed diagnosis code is payable. 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 billed services 
have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing billed for date of 
service December 6, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing care provided from September 15, 2021, 
to October 8, 2021. 
 
You asked the Plan to pay for the nursing care. You say that the care provided was medically necessary. The 
Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for subsequent nursing care provided from September 15, 2021, 
to October 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 23, 2022, billed 
with codes 81216, 81238, 81241, 81242, 81249, 81279, 81298, 81307, 81317, 81321, 81334, 81339, and 
81345. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
September 23, 2022, billed with codes 81216, 81238, 81241, 81242, 81249, 81279, 81298, 81307, 81317, 
81321, 81334, 81339, and 81345.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown - porcelain/ceramic (D2740) Tooth #6, 7, 10 and 
11. 
 
You asked the Plan to pre-approve dental services. You say that the service was not requested for cosmetic 
reasons. The Plan denied your request. The Plan says this service is not covered under your Plan. 

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. Crown - porcelain/ceramic 
(D2740) is not covered under the Plan's dental benefits 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D2740 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve crown - 
porcelain/ceramic (D2740) Tooth #6, 7, 10 and 11.