Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for radiological examination (procedure 71045) provided on August 26, 
2023. 
 
You asked the Plan to pay for radiological examination (procedure 71045). You say that you are requesting the 
claim be reviewed and reprocessed for payment. The Plan denied your request. The Plan says that the records 
do not support the services at issue in this case. 
 
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 71045 is radiologic examination, chest; single view. 
 
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 radiological examination (procedure 71045). Our reviewer 
says that the service at issue in this case is supported by the medical records. Our reviewer found there are 2 
separate single view chest x-rays, CPT 71045 done on 8/26/23. The first was signed at 10:23, while the second was done for a nasogastric (NG) tube placement and signed at 22:26 hours. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiological examination (procedure 71045) have been met. Therefore, we 
decided that the Plan has to pay for radiological examination (procedure 71045) provided on August 26, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the surgical extractions (D7210 x 4), simple extractions 
(D7140 x 7), alveoloplasty in conjunction with extractions (D7310) and removal of impacted tooth (D7220) 
provided on June 21, 2023.  
You asked the Plan to pay more for the dental services. You say that prior to your appointment you got dental 
coverage then your provider extracted all of your upper teeth. The Plan denied your request. The Plan says you 
are responsible for any charged amount above the Plans cost-sharing amount when your services are received 
from an out-of-network provider and x-rays are required in order for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. Medicare generally does not cover dental services. However, the Plan offers a 
dental benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. We 
looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if the Plans rules for coverage of the surgical extractions and removal of 
impacted tooth have been met. There are no x-rays or medical records to support the medical necessity or 
payment. Therefore, we decided that the Plan does not have to pay more for the surgical extractions (D7210 x 
4), simple extractions (D7140 x 7), alveoloplasty in conjunction with extractions (D7310) and removal of 
impacted tooth (D7220) provided on June 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 85060 billed for date of service June 8, 2023.  
 
You asked the Plan to pay for procedure code 85060. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not supported 
 
The Plan must follow Medicare rules. Medicare rules say that 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. Medicare rules also say that the provider, supplier, or beneficiary, as appropriate, must furnish to the 
intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
In this case, the MUE for CPT code 85060 is 1. The MAI value for this code is 3. You billed 2 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 procedure code 85060 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 85060 billed for date of service June 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custom fabricated abutment includes placement (D6057) 
and abutment supported porcelain crown (D6059) provided on September 28, 2023. 
 
You asked the Plan to pay for the dental services. You say that crowns are a covered benefit up to $2,000 per 
year. The Plan denied your request. The Plan says these services are not covered benefits 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 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 
custom fabricated abutment includes placement (D6057) and abutment supported porcelain crown (D6059) 
provided on September 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) (A4239) provided on 
June 28, 2023. 
 
You asked the Plan to pay for the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items denied correctly as the rendering provider is not 
enrolled with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (CGM) 
(A4239) provided on June 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the repair of a broken complete lower denture (D5511) 
provided by an out-of-network provider on August 23, 2023. 
 
You asked the Plan to pay for the dental service. You say that the provider told you that all charges would 
probably be paid and at the time you were not aware that the provider was out-of-network. 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 repair of a broken complete lower denture (D5511) provided by an out-of-network provider on 
August 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical nutrition therapy services provided on April 6, 2023, 
to June 2, 2023. 
 
You asked the Plan to pay for medical nutrition therapy services. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says you do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does 
not have to pay for medical nutrition therapy services provided on April 6, 2023, to June 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extraction of erupted tooth or exposed root (D7140) and 
mandibular partial denture (D5226) provided on August 29, 2023. 
 
You asked the Plan to pay for extraction of erupted tooth or exposed root (D7140) and mandibular partial 
denture (D5226). You say that these services were necessary for your health in order to stop further issues. The 
Plan denied your request. The Plan says the services are not covered under the member's contract under any 
normal circumstances. 
 
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 extraction 
of erupted tooth or exposed root (D7140) and mandibular partial denture (D5226) provided on August 29, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for collection of blood specimen (36416) provided on June 9, 
2022. 
 
You asked the Plan to pay for collection of blood specimen. You say that you have no knowledge of these 
services and should not be responsible for payment. The Plan denied your request. The Plan says procedure 
code 36416 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 36416 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 36416 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of collection of blood specimen have not been met. Therefore, we decided that the Plan does not have 
to pay for collection of blood specimen (36416) provided on June 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from July 12, 2023, to 
July 13, 2023. 
 
You asked the Plan to pay for the self-administered drugs. You say that the claim should be reprocessed and 
paid. The Plan denied your request. The Plan says the self-administered drugs are not covered under Medicare 
Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided from July 12, 2023, to July 13, 2023.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nuedexta capsules. 
 
You asked the Plan to pre-approve the medication. You say that this is effective for Pseudobulbar affect, and 
the patient has had treatment since September of 2019. The Plan denied your request. The Plan says the 
medication is not covered as a medical benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Nuedexta capsules.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from December 29, 
2022, to January 1, 2023. 
 
You asked the Plan to pay for the medication. You say that the medication is necessary and must be taken daily 
in a timely manner. The Plan denied your request. The Plan says the medication is not covered as a medical 
benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided from December 29, 2022, to January 1, 2023.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcatheter placement of an intravascular stent(s) 
(37238). 
 
You asked the Plan to pre-approve a transcatheter placement of an intravascular stent(s). The Plan denied your 
request. The Plan says this request 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 a transcatheter placement of an 
intravascular stent(s). Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found there is no documentation of severe, whole 
leg edema recalcitrant to less invasive treatments.  The severity and impact of the symptoms is unclear.  Our 
reviewer found there is no evidence of an iliac venous obstructive process on noninvasive imaging.  Our 
physician reviewer also found that the documentation does not satisfactorily support that the patient would be 
expected to experience meaningful improvement in their bilateral symptoms from the treatment in question. 
 
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 transcatheter placement of an intravascular stent(s) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a transcatheter placement of an intravascular 
stent(s) (37238).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Dayspring Active compression system and arm 
garment (K1024, K1025). 
 
You asked the Plan to pre-approve the Dayspring Active compression system and arm garment . You say that 
the items are medically necessary. The Plan denied your request. The Plan says this device is considered 
experimental. 
 
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 Dayspring Active compression 
system and arm garment. Our reviewer says that the requested items are not considered medically reasonable 
and necessary in this case. Our physician reviewer found this device is considered experimental. 
 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 Dayspring Active compression system and arm garment have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the Dayspring Active compression system 
and arm garment (K1024, K1025).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical additional radiographic image 
(D0230) provided on September 13, 2023. 
 
You asked the Plan to pay for the intraoral - periapical additional radiographic image. You say that this should 
be covered as this was for a yearly dental appointment and nothing extra was done on the visit. The Plan denied 
your request. The Plan says your benefit for the intraoral - periapical x-ray has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the intraoral - periapical x-ray was exhausted on date of service September 13, 2023. 
Therefore, we decided that the Plan does not have to pay for the intraoral - periapical additional radiographic 
image (D0230) provided on September 13, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is very motivated and needs a short-term 
intense rehabilitation program for maximal recovery. The Plan denied your request. The Plan says an IRF 
admission is not medically necessary, but skilled therapies as an outpatient, home with home healthcare, or at a 
skilled nursing facility may be approved upon request.  
 
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 pre-approve 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's 
medical problems are stable and there are no complex nursing or rehabilitation needs. 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 pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L1 kyphoplasty (22514). 
 
You asked the Plan to pre-approve L1 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet criteria. The onset of symptoms is now over 10 months 
ago and there is evidence of significant retropulsion. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific criteria are 
met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve L1 kyphoplasty. Our reviewer says that 
the enrollee does not meet criteria for coverage. Our physician reviewer found the records in this case do not 
document an acute or subacute osteoporotic VCF by recent (within 30 days) advanced imaging. The records 
also report fracture retropulsion/canal compromise, which is a relative contraindication to the 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 L1 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L1 kyphoplasty (22514).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service September 
18,2023. 
 You asked the Plan to pay for the billed testing. You say that the records support the testing. The Plan denied 
your request. The Plan says one code must be submitted for the panel. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
The panel testing was billed using codes 87481, 87500, 87640, 87652, and 87798. We looked at the file and 
Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is no 
evidence that multiple procedures, multiple methodologies, or multiple kits were used in this case. As such, a 
single code with one unit of service should be used. Based on this information, we decided that Medicare rules 
for coverage of the testing panel have not been met. Therefore, we decided that the Plan does not have to pay 
for the panel testing billed for date of service September 18,2023.