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

 
We decided that the Plan does not have to pay for the laboratory services (G0482 and 80307) provided on 
February 27, 2023. 
 
You asked the Plan to pay for the laboratory services. 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 supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the laboratory services have been met. 
In this case, the results of the provided laboratory services were not provided for review. Therefore, we decided 
that the Plan does not have to pay for the laboratory services (G0482 and 80307) provided on February 27, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88342 billed for date of service June 6, 2023. 
 
You asked the Plan to pay for procedure code 88342. You say that you bill separately from the facility. The 
Plan denied your request. The Plan says payment for code 88342 is bundled into payment for code 88189. 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 88342 is a column II code to column I code 88189. Code 88342 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 88342 
billed for date of service June 6, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code G0483 billed for date of service August 29, 2023. 
 
You asked the Plan to pay for the billed code. You say that the claim should be reprocessed. The Plan denied 
your request. The Plan says that there are no modifiers allowed with code pair 80307 and G0483. 
 
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 looked at the file and the rules. The PTP edits between presumptive tests and definitive tests were 
withdrawn. Code G0483 is separately payable in this case. Based on this information, we decided that 
Medicare rules for coverage of the billed code have been met. Therefore, we decided that the Plan has to pay 
for procedure code G0483 billed for date of service August 29, 2023.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration (D4266) and the bone 
replacement graft (D7953) for tooth #4 and #11 provided on July 24, 2023. 
 
You asked the Plan to pay for the dental services. You say that the EOC does not distinguish between a simple 
extraction and oral surgery and the services were necessary for the extraction. The Plan denied your request. 
The Plan says the denial of payment for these services is correct, because the guided tissue regeneration and the 
bone replacement graft 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 Plan's 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 the 
guided tissue regeneration (D4266) and the bone replacement graft (D7953) for tooth #4 and #11 provided on 
July 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical stent (D5982) and pedicle soft tissue graft procedure 
(D4270) provided on August 9, 2022, and August 9, 2023. 
 
You asked the Plan to pay for these dental services. You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for surgical 
stent (D5982) and pedicle soft tissue graft procedure (D4270) provided on August 9, 2022, and August 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the manual traction therapy provided by a chiropractor on 
August 4, 2023. 
 
You asked the Plan to pay for the manual traction therapy. You say that the claim should be reprocessed for 
payment. The Plan denied your request. The Plan says the only covered chiropractic service is manual 
manipulation of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the manual traction therapy provided by a chiropractor on August 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral periapical first radiographic image (D0220) 
provided on July 19, 2023. 
 
You asked the Plan to pay for 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 May 2, 2023. Therefore, 
we decided that the Plan does not have to pay for intraoral periapical first radiographic image (D0220) provided on July 19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve 
branches including imaging guidance, when performed (64624). 
 
You asked the Plan to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging 
guidance, when performed. You say that this is medically necessary. The Plan denied your request. The Plan 
says this is not medically necessary because based on the medical literature, this procedure is not considered 
standard of care for management of chronic knee pain. 
 
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 destruction by neurolytic agent, 
genicular nerve branches including imaging guidance, when performed. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this procedure is considered an experimental/ investigational procedure. It is the subject of ongoing 
clinical trials. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of destruction by neurolytic agent, genicular nerve branches including imaging 
guidance, when performed have not been met. Therefore, we decided that the Plan does not have to pre-
approve destruction by neurolytic agent, genicular nerve branches including imaging guidance, when 
performed (64624).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 single power option power wheelchair (PWC) 
(K0836) and accessories  
 
You asked the Plan to pre-approve A Group 2 Single Power Option PWC and accessories . You say that the 
items are medically necessary The Plan denied your request. The Plan says the items are not medically 
necessary 
 
The Plan follows Medicare rules. Medicare rules say that a group 2 PWC is covered if the criteria listed in the 
Medicare Rules section is met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a group 2 single power option PWC and 
accessories. Our reviewer says that the items are not medically necessary. Our physician reviewer found the 
enrollee does not have high risk for skin breakdown, use a catheter intermittently, have spasticity or require an 
alternative means of managing power drive. 
 
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 group 2 single power option PWC and accessories have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a group 2 single power option power 
wheelchair (PWC) (K0836) and accessories
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter implantation of wireless pulmonary artery 
pressure sensor (33289). 
 
You asked the Plan to pre-approve CardioMEMS. You say that this is medically necessary. The Plan denied 
your request. The Plan says the clinical value and effectiveness of the CardioMEMS device has not been 
demonstrated in the peer-reviewed literature. 
 
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 CardioMEMS. Our reviewer says that 
there remains a dearth of randomized, blinded clinical studies examining long-term clinical outcomes 
establishing the value of CardioMEMS in patient management. Our physician reviewer found at this time, the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollees clinical 
management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transcatheter implantation of wireless pulmonary artery pressure sensor (33289).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laparoscopy (57425, 58661) and revision of prosthetic 
vaginal graft (57426), provided on June 27, 2023. 
 
You asked the Plan to pay for the laparoscopy and revision of prosthetic vaginal graft. You say that the services 
were medically necessary. The Plan denied your request. The Plan says this provider does not participate in 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the laparoscopy (57425, 58661) and 
revision of prosthetic vaginal graft (57426), provided on June 27, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the SNF stay provided from November 21, 
2022, to December 13, 2022. 
 
You asked the Plan to reduce the cost share for the SNF stay. You say that the cost share should be 40%. 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 $0 
copayment each day for Medicare-covered days 1-20, $188 copayment each day for Medicare-covered days 
21-50 and $0 copayment for additional Medicare-covered days, up to 100 days. 
  You have been asked to pay a $2,444 for the SNF stay.  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
October 27, 202  
October 31, 2022 
SNF stay $1,975 $0 $0 
November 1, 2022 
November 7, 2022 
SNF stay $2,370 $0 $0 
November 21, 2022 
-November 30, 2022 
SNF stay $4,290 $188/day 21 $188 
December 1, 2022 
December 13, 2022 
SNF stay $5,148 $188/day 22-34 $2,256 
TOTAL:    $2,444 
 
This item/service falls within the skilled nursing facility (SNF) 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 reduce the cost share for the SNF stay provided from November 21, 2022, to December 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation and drugs or medicaments dispensed in 
the office for home use (D4921, D9630) provided on November 14, 2022. 
 
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 Plan's 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 and drugs or medicaments dispensed in the office for home use (D4921, D9630) provided on 
November 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for deep gum and root cleaning of the upper and lower right 
quadrants (D4341). 
 
You asked the Plan to pay for deep gum and root cleaning of the upper and lower right quadrants. 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 25, 2022. 
Therefore, we decided that the Plan does not have to pay for deep gum and root cleaning upper and lower right 
quadrants.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2311, E2313, E2377) and carry handles (K0108) for a power wheelchair.

You asked the Plan to pre-approve the expandable controller and carry handles. You say that these features are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that covered items must serve a medical purpose. An expandable controller is covered when medically 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 the expandable controller and carry handles. Our reviewer says that these features are not medically necessary. Our physician reviewer found there is not a medical need for the upgraded electronics. Additionally, the requested carry handles do not have a specific medical purpose and are therefore 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 expandable controller and carry handles have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2311, E2313, E2377) and carry handles (K0108) for a power wheelchair.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health care services. You asked the Plan to pre-
approve home health care services. You say that you are the only Spanish-speaking home health agency in the 
area. The Plan denied your request. The Plan says the enrollee must receive their care from a network provider. 
 
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. The enrollee is being referred to Enhabit 
Home Health, an in-network provider. The Plan has confirmed there is one Spanish-speaking clinician for 
every service area, and if the clinician is not available, they do have access to an interpreter line during the enrollees home health visits. 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 home health care services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown porcelain/ceramic tooth #8 (D2740). 
 
You asked the Plan to pre-approve crown porcelain/ceramic tooth #8. You say that this is medically necessary. 
The Plan denied your request. The Plan says this is not covered due to tooth wear. 
 
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 
porcelain/ceramic tooth #8 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 porcelain/ceramic tooth #8. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found tooth #8 is smaller in 
size compared to tooth #9. The x-ray is also undiagnostic. The contrast of the x-ray is poor, I am unable to 
visualize most of the teeth in the x-ray. Based on the information provided, D2740 for tooth #8 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 
the Plan's rules for coverage of crown porcelain/ceramic tooth #8 have not been met. Therefore, we decided 
that the Plan does not have to pre-approve crown porcelain/ceramic tooth #8 (D2740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on July 14, 2023. 
 
You asked the Plan to pay more for the dental services. You say that this should be covered. 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 dental services provided on July 14, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Grafix PRIME (Q4133). 
 
You asked the Plan to pre-approve Grafix PRIME. You say that this is medically necessary. The Plan denied 
your request. The Plan says records do not show that the wound is free of cancer and there is documentation of 
exposure of bone. 
 
The Plan follows Medicare rules. Medicare rules say that application of skin substitutes to ulcers or wounds 
can be covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Grafix PRIME. Our reviewer says that 
the enrollee does not meet criteria for coverage. Our physician reviewer found the enrollee underwent re-
excision of the cancer with biopsy results showing clear margins, so no evidence of residual cancer was present 
in the wound. However, the provided documentation described exposed bone, which doesn't meet criteria for 
skin grafting of the area. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Grafix PRIME have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Grafix PRIME (Q4133).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99203 billed for date of service May 22, 
2023. 
 
You asked the Plan to pay for the billed code. You say that the enrollee was seen in an urgent care facility. The 
Plan denied your request. The Plan says new patient qualifications were not 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. 
 We find that CPT code 99203 is not supported. The enrollee received an evaluation and management service 
from the same physician group practice, from a provider with the same specialty, within the previous 3 years. 
There is a more applicable code available for the services provided. Based on this information, we decided that 
Medicare rules for coverage of the billed code have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99203 billed for date of service May 22, 2023.