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

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device. 
 
You asked the Plan to pre-approve the Vertiflex Superion Interspinous device. You say that that the enrollee 
has suffered from their condition for six years which has greatly impacted their quality of life. The Plan denied 
your request. The Plan says the Vertiflex Superion Interspinous device 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 pre-approve the Vertiflex Superion Interspinous 
device. Our reviewer says that the Vertiflex Superion Interspinous device is not medically necessary. Our 
physician reviewer found that the Vertiflex device is considered experimental, and more research is needed. 
 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 Vertiflex Superion Interspinous device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 3, 2023, billed with 
codes 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81334 and 81351. 
 
You asked the Plan to pay for the genetic testing billed. You say that you have billed the services at issue 
correctly. 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 
July 3, 2023, billed with codes 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81334 and 81351.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93042 and 99291 billed for date of service 
November 29, 2022. 
 You asked the Plan to pay for procedure codes 93042 and 99291. You say that you have provided medical 
records to support payment. The Plan denied your request. The Plan says payment for code 93042 is bundled 
into payment for code 93010. The Plan also says that code 99291 is not supported by the medical record. 
 
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 93042 
is a column II code to column I code 93010. 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 for separate payment 
of code 93042 
 
In relation to code 99291, the CPT Code Manual definition of code 99291 is Critical care, evaluation and 
management of the critically ill or critically injured patient; first 30-74 minutes on a given calendar date of 
service. We find that CPT code 99291 is not supported in the medical record. Specifically, the code definition 
is time-based, and the records submitted for review do not document the total time spent providing the services 
described by this code. Based on this information, we decided that Medicare rules for coverage of 99291 have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 93042 and 99291 
billed for date of service November 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a portable x-ray provided on September 26, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for a portable x-ray . You say that this patient is in a facility, and you depend upon 
the facility staff for any verification or prior authorization. The Plan denied your request. The Plan says There 
was no preauthorization by a primary care provider (this is different than a referral) for an out-of-network 
(OON) provider or facility. 
 
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 a portable x-ray provided on September 26, 2023, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the liver elastography, mechanically induced shear wave 
(e.g., vibration), without imaging, with interpretation and report (91200) provided on August 1, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the diagnostic service. You say that please review the documents and reconsider 
the claim for payment. The Plan denied your request. The Plan says enrollees must receive their medical 
services from an in-network provider with the exception being urgent or emergent services. Non-emergent 
services with non-contracted providers require prior authorization before services being rendered.  
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 liver elastography, mechanically induced shear 
wave (e.g., vibration), without imaging, with interpretation and report (91200) 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 copayment for each wound debridement provided on 
August 08, 2023, to August 24, 2023. 
 
You asked the Plan to waive the copayment for each wound debridement. You say that you want to appeal the 
amount being charged. 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 $290 
copayment for outpatient hospital services. 
 
You have been asked to pay a $290 copayment for each wound debridement. This item/service falls within the 
outpatient hospital 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. The total you owe is $890 ($290 copayment x 3 visits = $890). Therefore, we decided that 
the Plan does not have to waive the copayment for each wound debridement provided on August 08, 2023, to 
August 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dentoalveolar structures - orthodontic treatment 
(code 41899). 
 
You asked the Plan to pre-approve the dental service. You say that your jaw is not aligned and you need this 
procedure to assist with helping get this fixed due to the medical issues that come along with it. You also say 
that you feel  this is a medical issue not a cosmetic issue. The Plan denied your request. The Plan says the 
request for orthodontics is not a covered benefit of your medical benefits. Additionally, you have a mandatory 
supplemental dental benefit, which also does not cover orthodontics. 
 
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 pre-approve the 
dentoalveolar structures - orthodontic treatment (code 41899).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cleaning (D1110) provided on August 31, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says 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 February 20, 2023. 
Therefore, we decided that the Plan does not have to pay for a cleaning (D1110) provided on August 31, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device. 
 
You asked the Plan to pre-approve the Vertiflex Superion Interspinous device. You say that the enrollee is 
experiencing multi-level bilateral facet-arthritis throughout the lumbar spine. You say that the enrollee exhibits 
positive facet loading and walks being forward to offload the facet joints. You say that the enrollee is unable to 
tolerate a three-level fusion surgery and the associated extensive recovery process. The Plan denied your 
request. The Plan says the Vertiflex Superion Interspinous device 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 pre-approve the Vertiflex Superion Interspinous 
device. Our reviewer says that the Vertiflex Superion Interspinous device is not medically necessary. Our 
physician reviewer found that the Vertiflex device is considered experimental, and more research is needed.  
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 Vertiflex Superion Interspinous device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. You say that the requested Injectafer is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Infed and Venofer first.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Injectafer. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the Plan requires a trial of drugs 
Infed and Venofer before they will approve the requested drug. In this case, the enrollee has not tried and failed 
the required drug(s). There is no documentation provided indicating that the Plans required drug(s) would 
likely be less effective and/or likely have adverse effects for the 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 7, 2023, to 
September 5, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that the NOA was sent timely. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA . Based on this information, we find that the Medicare rules for payment 
of the claim at issue have not been met. Therefore, we decided that the Plan does not have to pay for the home 
health services provided from August 7, 2023, to September 5, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 20, 2022, 
to October 12, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the NOA was submitted in a 
timely manner. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from September 20, 2022, to 
October 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing (81479) provided on September 26, 
2023. 
 
You asked the Plan to pay for procedure code 81479. 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 covered as billed. 
 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 shows that a unique identifier was reported. The 
unique identifier reported (ZB1CW) is used to report the Guardant360 test, which should also be reported with 
procedure code 0326U. Based on this information, we decided that Medicare rules for coverage of procedure 
code 81479 have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 
testing (81479) provided on September 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant crown (D6750) for teeth 6, 7, 8, 10, and 11, 
and false tooth for bridge (D6240) for tooth 9. 
 
You asked the Plan to pre-approve an implant crown for teeth 6, 7, 8, 10, and 11, and false tooth for bridge for 
tooth 9. You say that you need the services. The Plan denied your request. The Plan says double abutments are 
not authorized for fixed prosthetics. 
 
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 pre-approve an 
implant crown (D6750) for teeth 6, 7, 8, 10, and 11, and false tooth for bridge (D6240) for tooth 9.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture - cast metal framework with 
resin denture bases (D5213). 
 
You asked the Plan to pre-approve the maxillary partial denture. You say that you only used your dentures for 
more or less 3 years and it was broken and it cracked on the left side. You also say that you went to your dentist 
to get it fixed but the dentist said it needs to be replaced. The Plan denied your request. The Plan says your 
benefit for the maxillary partial 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 December 15, 2020. Therefore, 
we decided that the Plan does not have to pre-approve a maxillary partial denture - cast metal framework with 
resin denture bases (D5213).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is necessary to address 
pain and restore function. The Plan denied your request. The Plan says this procedure is not supported by 
research and is not covered. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no imaging showing only modic changes without facet degenerative joint 
disease or stenosis. The cause of pain is not clear. 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drugs or medicaments dispensed in the office for home 
use (D9630) provided on August 25, 2023. 
 
You asked the Plan to pay for the drugs or medicaments. You say that you called the plan and were told this 
would be covered. The Plan denied your request. The Plan says this service is not covered because it is 
excluded from your healthcare plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the drugs 
or medicaments dispensed in the office for home use (D9630) provided on August 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided by an out-of-network provider on June 27, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you submitted all the required 
documents and would like the claim processed. The Plan denied your request. The Plan says the documentation 
requirements have not been met. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. Specifically, there is no signed receipt of the delivery. 
The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous glucose 
monitor (CGM) provided by an out-of-network provider on June 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-bond of crowns (D2920 x 2), prefabricated post and 
core in addition to crown (D2954), endodontic therapy (D3330), re-bond of fixed partial dentures (D6930 x 2) 
provided on July 26, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested items or services was exhausted on date of service April 10, 2023. 
Therefore, we decided that the Plan does not have to pay for the re-bond of crowns (D2920 x 2), prefabricated 
post and core in addition to crown (D2954), endodontic therapy (D3330), re-bond of fixed partial dentures 
(D6930 x 2) provided on July 26, 2023.