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

 
We decided that the Plan does not have to pre-approve CardioMEMS implant. 
 
You asked the Plan to pre-approve CardioMEMS implant. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested services are 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 pre-approve CardioMEMS implant. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has recurrent congestive heart failure (CHF). The CardioMEMS device 
was approved by the Food and Drug Administration (FDA) in 2014 and consists of a sensor device placed in 
the pulmonary artery to allow measurement of pulmonary artery pressure in the management of patients with 
CHF. The clinical study on which FDA approval was based showed improved clinical outcomes and decreased hospitalizations in patients in whom the CardioMEMS system was implanted, reflecting a patient population 
with preserved ejection fraction and was somewhat limited in scope. Subsequent follow-up studies remain 
encouraging and suggest an improvement in heart failure symptoms with the use of the device. In addition, 
published expert opinion in the cardiology literature is supportive of the clinical usefulness of CardioMEMS. 
Nonetheless, there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, 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 implant have not been met. Therefore, we decided that the Plan 
does not have to pre-approve CardioMEMS implant.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), 
and prophylaxis - adult (D1110) provided on October 3, 2023. 
 
You asked the Plan to pay for the dental services. You say that you did not know that cleanings were only 
covered twice a year and you were misled by the dental office. The Plan denied your request. The Plan says 
your benefit for the requested services 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 services was exhausted on date of service January 18, 2023, and May 24, 
2023. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation - established 
patient (D0120), and prophylaxis - adult (D1110) provided on October 3, 2023.  
 
Your complaint about being misled by the provider is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the TERT (telomerase reverse transcriptase) gene analysis 
billed with code 81345 and the oncology gene expression profiling billed with code 0089U for date of service 
August 29, 2023. 
 
You asked the Plan to pay for the TERT gene analysis and the oncology gene expression profiling. You say 
that you disagree with the Plan's denial. The Plan denied your request. The Plan says the services rendered are 
not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic tests that have been approved by a 
specific diagnostic program only are covered. Medicare rules also say that submitted claims in which the unit 
of service exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying 
the excess units. 
 
We looked at the file and Medicare rules. Review of the file shows that the testing rendered is not listed as a 
covered test on the DEX Diagnostics Exchange. This means code 81345 is not covered. In this case, the MUE 
for CPT code 0089U is 1. The MAI value for this code is 3. You billed 6 units of this code, exceeding the 
MUE. You did not provide all the required evidence showing that the excess units were actually provided, were 
correctly coded, and were medically necessary. 
 
Based on this information, we decided that Medicare rules for coverage of the TERT gene analysis and the 
oncology gene expression profiling have not been met. Therefore, we decided that the Plan does not have to 
pay for the TERT (telomerase reverse transcriptase) gene analysis billed with code 81345 and the oncology 
gene expression profiling billed with code 0089U for date of service August 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 19, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior authorization. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The referring provider is not a 
network provider with the Plan. The Plan had network providers available who could have provided the 
items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no 
exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does 
not have to pay for the laboratory services provided on July 19, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM), supplies and 
accessories provided on June 30, 2023. 
 
You asked the Plan to pay for the CGM, supplies and accessories. You say that you have submitted proof of 
delivery along with other supporting documentation, but the claim keeps denying for missing this information. 
The Plan denied your request. The Plan says the provider is not a plan contract provider and is not enrolled in 
Medicare as a durable medical equipment supplier. 
 
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 a continuous glucose monitor (CGM), 
supplies and accessories provided on June 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immediate denture - maxillary (D5130) provided on 
August 3, 2023. 
 
You asked the Plan to pay for immediate maxillary denture. You say that you could not eat and needed this 
service. The Plan denied your request. The Plan says your benefit for the maxillary denture 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 service was exhausted on date of service January 25, 2023. Therefore, we 
decided that the Plan does not have to pay for the immediate denture - maxillary (D5130) provided on August 
3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction provided on July 3, 2023. 
  
You asked the Plan to pay for the refraction. You say that the refraction should be covered because it was not 
for a medical issue and was routine. The Plan denied your request. The Plan says the service is not a covered 
benefit. 
 
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 these services when received during a routine eye exam. 
 
We looked at the file and the Plan's rules. Specifically, the record shows a diagnosis of age-related cataracts 
which is medical in nature. This means that the refraction was not provided during a routine visit. Based on this 
information, we decided that the Plan's rules for coverage of the refraction have not been met. Therefore, we 
decided that the Plan does not have to pay for the refraction provided on July 3, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for date of service November 
28, 2022. 
 You asked the Plan to pay for procedure code 99284. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 99284 is bundled into payment for code 99285. 
 
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 99284 
is a column II code to column I code 99285. 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 99284 billed for date of service November 28, 
2022.
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 this is medically necessary. The Plan denied your 
request. The Plan says this may be provided at a lower level of 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 that the clinical documentation shows that the enrollee has had clinical and functional 
status change thus would be expected to require ongoing assessment and treatment by skilled nursing and 
skilled therapy. The clinical documentation shows that patient's past level of function was modified 
independent with wheelchair mobility and seated self care tasks now requiring supervision with wheelchair 
mobility and self care tasks and there are no specified daily skilled therapy goals. The clinical documentation 
does not specify any daily skilled nursing needs thus daily skilled services are not supported. As a practical 
matter, clinical documentation does not support 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient visit for the evaluation and management 
provided on May 10, 2022, to December 21, 2022. 
 
You asked the Plan to pay for an outpatient visit for the evaluation and management. You say that you are 
requesting reconsideration for the denied claim. The Plan denied your request. The Plan says this provider 
opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an 
outpatient visit for the evaluation and management provided on May 10, 2022, to December 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150), intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional 
radiographic image (D0230), and bitewings - four radiographic images (D0274) provided on August 29, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were never informed at your appointment 
that the provider was not in-network. You also say that they wont reduce your charges even though you were 
misinformed by the provider. 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 the comprehensive oral evaluation - new or established patient (D0150), intraoral - periapical first 
radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230), and bitewings - 
four radiographic images (D0274) provided on August 29, 2023.  
 
Your complaint about not being informed that the provider was not in-network is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes G2066 and 93298 provided on August 1, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for codes G2066 and 93298. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for codes G2066 and 93298 provided on August 1, 
2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the office visit provided on August 30, 2023. 
 
You asked the Plan to waive the cost share for the vision service. You say that this service was covered in 2022 
with a $0 copayment. 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 $35 
copayment for vision services.  
 
You have been asked to pay a $35 copayment for the vision service. This service falls within the vision 
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 share for the office visit provided on 
August 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 7, 2023, billed with 
codes 81225. 
 
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 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 
April 7, 2023, billed with codes 81225.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the device evaluation services rendered on August 1, 2023, 
to September 1, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior authorization. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services 
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not 
have to pay for the device evaluation services rendered on August 1, 2023, to September 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual wellness visit provided on August 16, 2023. 
 
You asked the Plan to pay for an annual wellness visit. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says you had the annual wellness visit on July 24, 2023. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for an annual wellness visit provided on August 16, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) billed with code 
E0675 for March 6, 20230, to April 4, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that claims for E0675 will be denied as not 
reasonable and necessary.  
 
We looked at the file and Medicare rules. The services at issue are a PCD coded E0675. These services are 
denied by Medicare as not medically necessary. Therefore, we decided that the Plan does not have to pay for 
the pneumatic compression device (PCD) billed with code E0675 for March 6, 20230, to April 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 15, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services rendered are not a covered benefit when provided by an 
OON 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 15, 
2023, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96372 for date of service July 20, 2023. 
 
You asked the Plan to pay for procedure code 96372. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
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 96372 is therapeutic, prophylactic, or diagnostic injection 
(specify substance or drug); subcutaneous or intramuscular. 
 
We find that CPT code 96372 is not payable as billed. Specifically, code 96372 has a status indicator of Q1. 
Procedure code 99284 was billed and paid on the same claim, with the same date of service with a revenue 
code of 450. This gives code 99284 a status indicator of V. This gives procedure code 96372 has a status 
indicator of Q1 and is therefore, not separately payable. Based on this information, we decided that Medicare 
rules for coverage of procedure code 96372 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 96372 for date of service July 20, 2023.