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

 
We decided that the Plan does not have to pay for critical care services (procedure code 99292) rendered on 
October 15, 2022. 
 
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 Current Procedural Terminology (CPT) code 99292 remains 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 code 99292 is "Critical care, evaluation and management of 
the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for 
primary service)." 
 
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 the documentation does not 
support than an additional 30 minutes of critical care time was rendered. 
 
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 critical care services (procedure code 99292) rendered on October 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam CT (D0367) provided on December 2, 2022. 
 
You asked the Plan to pay for cone beam CT. 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 cone 
beam CT (D0367) provided on December 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (E0466) for nine months. 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is medically necessary. The 
Plan denied your request. The Plan says the ventilator is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the home ventilator. Our physician 
reviewer found the review has determined that this enrollee has chronic respiratory failure consequent to 
chronic obstructive pulmonary disease, The documentation in the medical record does not support that the 
ventilator at issue is medically necessary and reasonable for this enrollee. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (E0466) for nine months.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the third level injection provided on February 28, 2023. 
 
You asked the Plan to pay the injection. The Plan denied your request. The Plan says that the injection is not 
medically 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 pay for the injection. Our reviewer says that the 
enrollee did not meet the LCD coverage criteria. Our physician reviewer found that there was no extraordinary 
circumstance documented. The LCD has a utilization limit of 2 levels per session. Therefore, the third level 
injection is not 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pay for the third level injection provided on February 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 20, 2023, billed with 
procedure code 37197-59. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 37197-59 is Transcatheter retrieval, percutaneous, of 
intravascular foreign body (eg, fractured venous or arterial catheter), includes radiological supervision and 
interpretation, and imaging guidance (ultrasound or fluoroscopy), when 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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the procedure report does not include 
documentation of Percutaneous transcatheter retrieval of an intravascular foreign body (fractured venous or 
arterial catheter), including radiological supervision and interpretation, and imaging guidance (ultrasound or 
fluoroscopy).  For code 37197, the provider removes a foreign body from a blood vessel using a catheter he 
places through the skin. This code includes radiological supervision and interpretation, which the provider may 
use for guiding the catheter to remove the foreign body. Therefore, this procedure cannot be verified. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on March 20, 2023, billed with procedure code 
37197-59.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant  
(D6010), custom fabricated abutment  includes placement (D6057), and abutment supported porcelain fused 
to metal crown (noble metal) (D6061). 
 
You asked the Plan to pre-approve the dental services represented by codes D6010, D6057, D6061, D4341, 
D6240, and D4260. You say that you would like to know if the denied dental services can be approved. The 
Plan denied your request. The Plan says these services are not covered under your Medicare 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 dental services represented by 
codes D6010, D6057, and D6061 are not among those covered under this benefit. Therefore, we decided that 
the Plan does not have to pre-approve surgical placement of implant body: endosteal implant  (D6010), custom 
fabricated abutment  includes placement (D6057), and abutment supported porcelain fused to metal crown 
(noble metal) (D6061).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral hygiene instructions (D1330) and pulp cap - indirect 
(excluding final restoration) (D3120) provided on March 23, 2023, to March 30, 2023. 
 
You asked the Plan to pay for oral hygiene instructions and pulp cap. 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 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 oral 
hygiene instructions (D1330) and pulp cap - indirect (excluding final restoration) (D3120) provided on March 
23, 2023, to March 30, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code Q4244 provided on June 16, 2022. 
 
You asked the Plan to pay for Q4244. You say that there is a corrected claim. The Plan denied your request. 
The Plan says the documentation does not support that Procenta was administered. 
 
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 Q4244 is Procenta, per 200 milligrams. 
 
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 Q4244. Our reviewer says that this code does not meet 
criteria for payment. Our reviewer found Q4244 is not the most appropriate code. The record states a human 
cellular tissue product was injected. There is a more appropriate code to report for this substance. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Q4244 have not been met. Therefore, we decided that the Plan does not have to 
pay for code Q4244 provided on June 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Imaging services provided on April 4, 2023, billed with 
procedure code 75774-26-59. 
 
You asked the Plan to pay for the Imaging services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says payment for this service is bundled into payment 
of another service. 
 
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 75774 is a column II code to column I code 37236; however, 75774 
was billed with a modifier.  
 
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 Imaging services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that in this case, intravascular stent was 
performed, which includes radiological supervision and interpretation. Therefore, this procedure cannot be 
verified as a separate procedure. 
 
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 Imaging services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for Imaging services provided on April 4, 2023, billed with procedure code 
75774-26-59.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the application of desensitizing medicament (D9910). 
 
You asked the Plan to pre-approve the dental services represented by codes D2740, D2952, D3330 and D9910. 
The Plan denied your request. The Plan says the application of desensitizing medicament is not covered on 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 the application of 
desensitizing medicament (D9910).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup (D2950) and pontic-porcelain (D6242) provided 
on April 3, 2023. 
 
You asked the Plan to pay for core buildup (D2950) and pontic-porcelain (D6242). You say that you were told 
that a bridge would be covered. The Plan denied your request. The Plan says these services are 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.  

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 core 
buildup (D2950) and pontic-porcelain (D6242) provided on April 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 for date of service April 14, 2023. 
 
You asked the Plan to pay for procedure code J3490. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not separately payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that when a surgery is performed, certain services are 
included in the price of the surgery itself and are not separately payable. 
 
We looked at the file and Medicare rules. Review of the file shows that surgery procedure 64490 was provided 
on the same date of service. Code 64490 has a global surgery value of 0 days. Code J3490 was billed within the 
global surgery period of procedure 64490 without an appropriate modifier. This means code J3490 is not 
separately payable as billed. Based on this information, we decided that Medicare rules for coverage of 
procedure code J3490 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code J3490 for date of service April 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup (D2950). 
 
You asked the Plan to pre-approve core buildup (D2950). You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says this service is not a covered expense under your dental 
plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 pre-approve core 
buildup (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bone replacement graft (D7953) and therapeutic parenteral 
drug, single administration (D9610) provided on April 7, 2023. 
 
You asked the Plan to pay for bone replacement graft and therapeutic parenteral drug. 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 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 bone 
replacement graft (D7953) and therapeutic parenteral drug, single administration (D9610) provided on April 7, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that you would prefer 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 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and 
services provided from July 20, 2022, to July 26, 2022. 
 
You asked the Plan to pay for IRF care. You say that the services were medically necessary. The Plan denied 
your request. The Plan says the IRF services you are requesting do not meet the requirements for approval after 
July 19, 2022. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pay for acute inpatient rehabilitation facility (IRF) admission and services provided from July 20, 2022, to 
July 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate (20939). 
 
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 requested bone marrow aspirate, 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 (20939).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network specialist visit provided on 
January 19, 2023. 
 
You asked the Plan to waive the copayment for an in-network specialist visit. You say that the provider yelled 
and belittled you, then dismissed you without giving you the injections. 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 $30 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $30 copayment for an in-network specialist visit. This item/service falls within 
the physician/practitioner services, including doctors office visits 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 an in-network specialist visit provided on January 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the acupuncture treatments (97810, 97811) 
provided on February 22, 2022 and March 1, 2022. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these services are not payable as 
the claim was submitted untimely.  
 
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. 
 
The record shows that a claim for the acupuncture treatments provided on February 22, 2022 and March 1, 
2022 was not filed until March 28, 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 issue reimbursement 
for the acupuncture treatments (97810, 97811) provided on February 22, 2022 and March 1, 2022.