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

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided on 
October 20, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says this device is not covered. 

The Plan must follow Medicare rules. Medicare rules say that a PCD coded as E0675 is used only for 
peripheral artery disease. 
 
We looked at the file and Medicare rules. The record does not show that this device was received for peripheral 
artery disease. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device 
(E0675) provided on October 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87652 billed for date of service January 24, 
2023. 
 
You asked the Plan to pay for procedure code 87652. You say that you have billed the service at issue 
correctly. The Plan denied your request. The Plan says the provided records do not support the service 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 87652 is: Infectious agent detection by nucleic acid 
(DNA or RNA); Streptococcus, group A, quantification. 
 
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 procedure code 87652. Our reviewer says that procedure 
code 87652 does not meet criteria for payment. Our reviewer found that the laboratory report does not include 
documentation to support quantification. Procedure code 87652 therefore 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 procedure code 87652 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87652 billed for date of service January 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2752) for tooth numbers 29. 
 
You asked the Plan to pre-approve the dental services. You say that you are in pain and the crowns are 
necessary. The Plan denied your request. The Plan says the request is not medically necessary. 
 
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. The Plan covers the dental 
services when the services are medically necessary and reasonable. The rules say a crown can be replaced if 
there is evidence showing decay or a missing or broken crown. 
 
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 dental services. Our reviewer says 
that the request is not medically necessary. Our physician reviewer found that the provided x-rays are not of 
diagnostic quality and a determination for the replacement on whether the procedure is medically necessary 
cannot be made.  
 
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 the dental services have been met. Therefore, we decided that the Plan does not 
have to pre-approve a crown (D2752) for tooth numbers 29.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the new patient medical eye exam provided on March 24, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the medical eye exam. You say that the provider is in-network. The Plan denied 
your request. The Plan says enrollees 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 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 item/service 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 this item/service. Therefore, 
we decided that the Plan does not have to pay for the new patient medical eye exam provided on March 24, 
2023, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital level of care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the inpatient level of care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient care are met in this case. 
Our physician reviewer found that you have a mass for which the Plan has approved surgical removal. The 
approved procedure to remove the tumor is not on the inpatient only list. There is no documentation that you 
are at risk for obstruction of blood vessels (thromboembolism) and require intravenous (IV) blood thinners. 
The records do not support a reasonable expectation that you will require at least two midnights of inpatient 
hospital care for the approved procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient hospital level of care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798 billed for November 15, 2022. 
 
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 procedure code 87798 is 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 87798 is infectious agent detection by nucleic acid (DNA 
or RNA), not otherwise specified; amplified probe technique, each organism. 
 
We find that CPT code 87798 is not supported in the medical record. Specifically, there are no records to 
support the infectious agent detection was performed for the date of service at issue. Based on this information, 
we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 87798 billed for November 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition, endoskeletal, knee-shin system, stance 
flexion feature, adjustable (L5845). 
 
You asked the Plan to pre-approve a prosthetic. You say that the requested flexion feature is necessary. The 
Plan denied your request. The Plan says one knee component is already included with the approved knee. This 
cannot be requested separately. 
 
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 a prosthetic. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found a level 3 ambulator has the ability or potential for ambulation with variable cadence. Typical of 
the community ambulator who has the ability to traverse most environmental barriers and may have vocational, 
therapeutic or exercise activity that demands prosthetic utilization beyond simple locomotion. The 
documentation does not support that the enrollee requires the requested components for the authorized 
prosthesis. There is a knee component authorized with the prosthesis, an additional component for the knee is 
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 a prosthetic have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an addition, endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement grafts (D7953) for tooth #2, #5, #8, #9, 
#10, #11, and #12 provided on February 13, 2023. 
 
You asked the Plan to pay for the dental services. You say that the bone replacement grafts are covered by your 
medical coverage. The Plan denied your request. The Plan says the denial of authorization for these services is 
correct, because the bone replacement grafts 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 bone 
replacement grafts (D7953) for tooth #2, #5, #8, #9, #10, #11, and #12 provided on February 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mechanical traction therapy (97012), manual therapy 
(97140), and the therapeutic exercises (97110) provided on March 30, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit.  
 
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 services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the mechanical traction therapy (97012), manual therapy (97140), and the 
therapeutic exercises (97110) provided on March 30, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a biopsy provided on March 7, 2023, by an out-of-network 
(OON) provider.   

You asked the Plan to pay for a biopsy. You say that Medicare rules say that any Medicare provider can be 
used. The Plan denied your request. The Plan says this was not authorized. 
 
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 biopsy provided on March 7, 2023, by an out-of-
network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20930 billed for date of service January 30, 
2023. 
 
You asked the Plan to pay for procedure code 20930. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 20930 is considered bundled 
and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 20930 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 20930 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 20930 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 20930 billed for date of service January 30, 2023.
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) provided on April 5, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit.  
  
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 services provided 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) provided on April 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extractions (D7210 x7). 
 
You asked the Plan to pre-approve extractions (D7210 x14). You say that you are in pain and need your teeth 
extracted so you can then get dentures The Plan denied your request. The Plan says the services are not eligible 
for coverage under the medical benefit. The Plan also 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 Plan 
allows eight extractions every calendar year. The record shows you received one extraction on June 22, 2023 
which left seven remaining extractions available for the calendar year. The record shows your benefit for the 
requested item or service was exhausted on August 6, 2023 when the Plan approved seven extractions. The 
Plan's dental benefit limits of eight extractions per calendar year have been met for 2023. Therefore, we 
decided that the Plan does not have to pre-approve extractions (D7210 x7).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam (D0382) and to waive the coinsurance for the 
radiographic/surgical implant index (D6190) provided on March 15, 2023. 
 
You asked the Plan to pay for or waive the coinsurance for the dental services. You say that the cone beam 
took 5 seconds, and you were not given the correct price for the implants. The Plan denied your request. The 
Plan says the denial of payment for the cone beam is correct because it is not covered by the Plan. Also, the 
proper cost share was applied to the radiographic/surgical implant index. 
 
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 50% 
coinsurance for the radiographic/surgical implant index. 
 
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 total allowed amount for the radiographic/surgical implant index was $440 and the total coinsurance 
amount was $220 ($440 allowed x 50% coinsurance). 
 
You have been asked to pay a 50% coinsurance for the radiographic/surgical implant index. This item/service 
falls within the dental 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. Though the Plan offers a dental benefit in excess of Medicare coverage, the cone beam is 
not covered under the Plans dental benefit. Therefore, we decided that the Plan does not have to pay for a cone 
beam (D0382) and to waive the coinsurance for the radiographic/surgical implant index (D6190) provided on 
March 15, 2023.  
 
Your complaint about the estimates and billing procedures 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the caries risk assessment and documentation (D0603) 
provided on April 3, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit.  
 
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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the caries risk 
assessment and documentation (D0603) provided on April 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service January 31, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 99100 is considered bundled 
and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service January 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 5, 2022, billed 
with codes 81231, 81232, 81291, 81306, 81335 and 81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was necessary and is supported in 
the medical record. 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 
December 5, 2022, billed with codes 81231, 81232, 81291, 81306, 81335 and 81238.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 additional electroconvulsive therapy visits (90870).  
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of 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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case.  
  
Our physician reviewer found that you are requesting a pre-service reimbursement of additional 
Electroconvulsive Therapy (ECT) for the treatment of Schizoaffective Disorder Bipolar Type and Anxiety 
Unspecified. Based upon the review of the records provided, you have been stabilized and are no longer acting 
out or showing any behaviors. You have been compliant with treatment and medications. You are not showing 
any depressive symptomatology, suicidal or homicidal ideation, or negative behaviors. You have been calm 
and cooperative according to the documentation. Based on the information provided, you do not meet criteria 
for the continued use of Electroconvulsive Therapy (ECT). Additional treatments are not reasonable or 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 9 additional electroconvulsive therapy visits (90870).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the life sustaining oxygen and oxygen supplies provided on 
November 24, 2022. 
 
You asked the Plan to pay for the ambulance transport, ground mileage and supplies. The Plan denied your 
request. The Plan says procedure code A0422 is included in the ambulance fee schedule base payment rate and 
are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance supplies are considered part of the 
general ambulance service and payment for them is included in the payment rate for the transport. Therefore, 
we decided that the Plan does not have to pay for the life sustaining oxygen and oxygen supplies (A0422) 
provided on November 24, 2022.