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

 
We decided that the Plan does not have to pre-approve a therapeutic sacroiliac joint (SIJ) injection (27096). 
 
You asked the Plan to pre-approve an SIJ injection. You say that the requested service is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says the requested service 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 an SIJ injection. Our reviewer says that 
the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no documentation of at least 3 positive findings with provocative maneuvers. Additionally, 
the exam findings and prior magnetic resonance imaging (MRI) scans show other potential causes for the 
enrollee's chronic low-back pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an SIJ injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a therapeutic sacroiliac joint (SIJ) injection (27096).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a DePuy Synthes fibergraft allograft. 
 
You asked the Plan to pre-approve a DePuy Synthes fibergraft allograft. You say that the enrollee needs the 
surgery. You also say that it is already scheduled. The Plan denied your request. The Plan says the clinical 
value and effectiveness of the DePuy Synthes Fibergraft Allograft in the setting of anterior cervical spine 
fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 DePuy Synthes fibergraft allograft. Our reviewer says that the requested DePuy Synthes fibergraft allograft is not considered medically reasonable 
and necessary in this case. Our physician reviewer found there is insufficient reliable evidence in the peer-
reviewed medical literature to establish the safety and efficacy of the requested product for use in cervical 
fusion procedures. The requested item is considered coverage of a non-FDA-approved indication ("off-label" 
use) which is considered investigational. There is no documentation the enrollee is participating in a clinical 
trial or study. The gold standard for cervical spine fusions remains an autograft. The review has determined that 
the requested allograft is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a DePuy Synthes fibergraft allograft have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a DePuy Synthes fibergraft allograft.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the presumptive drug testing (80307) provided August 23, 
2023 
 
You asked the Plan to pay for the laboratory testing. You say that this claim was denied in error as a duplicate. 
Please reprocess and pay this claim. The Plan denied your request. The Plan says the service for CPT code 
80307 is redundant/duplicate and has been performed by the same and/or different provider on the same date of 
service.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we find that CPT code 80307 is not supported in the medical record. Specifically, per claims 
history, CPT code 80305: presumptive drug class screening, was paid on for date of service August 23, 2023, 
to another provider. Medicare does not pay for duplicate testing. Based on this information, we decided that 
Medicare rules for coverage of the laboratory testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the presumptive drug testing (80307) provided August 23, 2023
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve small alum rigid side guards (K0108 x2). 
 
 You asked the Plan to pre-approve the small alum rigid side guards. The Plan denied your request. The Plan 
says the requested side guards are not considered to be primarily medical in nature. The Plan also says that this 
is utilized to prevent clothing from getting caught between the wheels and chair, and does not serve a medical 
purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve small alum rigid side guards (K0108 x2).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87653 for date of service April 26, 2023. 
 
You asked the Plan to pay for procedure code 87653. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are 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 87653 is infectious agent detection by nucleic acid (DNA 
or RNA); Streptococcus, group B, amplified probe technique. 
 
We find that CPT code 87653 is not supported in the medical record. Specifically, the documentation did not 
include any results for Streptococcus, group B. The provider has listed a result for Streptococcus pyogenes 
which per the Centers for Disease Control and Prevention is Group A Streptococcus. There is a more 
appropriate code to be billed for the services rendered. Based on this information, we decided that Medicare 
rules for coverage of procedure code 87653 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 87653 for date of service April 26, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the mastopexy services, breast augmentation, and the 
complex repair of wound to arm. 
 
You asked the Plan to pre-approve the mastopexy services, breast augmentation, and the complex repair of 
wound to arm. You say that you have been having issues with your breast implants for two years. You say that 
you are in pain and have had two biopsies. You say that it is urgent that you get either new breast implants or 
have them removed entirely. The Plan denied your request. The Plan says the requested procedures are 
considered cosmetic in nature and not a covered benefit.  
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 mastopexy services, breast 
augmentation, and the complex repair of wound to arm. Our reviewer says that the mastopexy services, breast 
augmentation, and the complex repair of wound to arm are not medically necessary. Our reviewer found that 
the record indicated that you have breast implants and have had brachioplasty following weight loss. Although 
the record documents grave intravenous (IV) contracture, implant removal is not requested. The records 
provided does not document that the requested service is to treat functional impairments. The records supports 
that the requested service is for cosmetic purposes. Furthermore, the records provided does not establish the 
medical necessity and reasonableness, as defined by Medicare rules, of the requested service. Therefore, the 
elements of the coverage criteria are not satisfied, and the requested service is not recommended. 
 
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 mastopexy services, breast augmentation, and the complex repair of wound 
to arm have not been met. Therefore, we decided that the Plan does not have to pre-approve the mastopexy 
services, breast augmentation, and the complex repair of wound to arm.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 87471, 87481, 
87551, 87640, 87641, 87651, 87653, and 87798 provided May 4, 2023.  

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 are not payable as billed. 
 
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.  
 
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 laboratory services billed with codes 87471, 87481, 87551, 87640, 87641, 
87651, 87653, and 87798 provided May 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87640 billed for date of service August 1, 
2023. 
 
You asked the Plan to pay for procedure code 87640. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 87640 is bundled into payment for code 87641. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules state that providers may bill services 
with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. 
 
In this case, we have confirmed that code 87640 is a column II code to column I code 87641. Code 87640 was 
billed with modifier -59; however, the medical records provided do not show that the service billed with the -59 
modifier is a distinct procedural service. 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 87640 billed for date of 
service August 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fixed partial denture sectioning (D9120) provided on July 28, 
2023. 
 
You asked the Plan to pay for fixed partial denture sectioning (D9120). You say that you were referred to a 
provider by the Plan. You also say that he was not available, but another provider in the office was and both 
providers follow the same insurance. The Plan denied your request. The Plan says there is no coverage for 
fixed partial denture sectioning. 
 
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 fixed 
partial denture sectioning (D9120) provided on July 28, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (99285) provided on June 30, 
2023. 
 
You asked the Plan to pay for the emergency room services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid 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. 
 
We find that CPT code 99285 is not supported in the medical record. Specifically, this claim was 
inappropriately billed with the CS modifier after the end of the public health emergency. Based on this 
information, we decided that Medicare rules for coverage of the emergency room services have not been met. 
Therefore, we decided that the Plan does not have to pay for emergency room services (99285) provided on 
June 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endosteal implant (D6010) for tooth #12. 
 
You asked the Plan to pre-approve D6010. You say that this dental work is medically necessary. The Plan 
denied your request. The Plan says required information was requested and not provided. 
 
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 Plan covers D6010 when 
the services are medically necessary and reasonable.  
 
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 D6010. Our reviewer says that D6010 
is not medically necessary for tooth #12. Our physician reviewer found the space in between tooth #11 and tooth #13 is very small as the teeth have drifted into the space where tooth #12 once was. There is not enough 
room for an implant in this area. 
 
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 D6010 have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an endosteal implant (D6010) for tooth #12.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for an office visit provided on July 26, 2023. 
 
You asked the Plan to reduce the coinsurance for an office visit. You say that you disagree with the cost share. 
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 40% 
coinsurance for out-of-network physician/practitioner services, including doctors office visits. 
 
You have been asked to pay 40% coinsurance for an office visit. This item/service falls within the out-of-
network physician/practitioner services, including doctors office visits benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The total amount you owe is $50.01 
($125.02 x 40% = $50.01). Therefore, we decided that the Plan does not have to reduce the coinsurance for an 
office visit provided on July 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9999 billed for date of service July 19, 
2023. 
 
You asked the Plan to pay for procedure code S9999. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
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 S9999 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9999 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9999 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9999 billed for date of service July 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walker provided on September 25, 2023. 
 
You asked the Plan to pay for the walker. You say that you are requesting reconsideration for the services 
provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the walker provided on 
September 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a wig (A9282) purchased May 22, 2023. 
 
You asked the Plan to reimburse you for a wig. You say that you are requesting reimbursement for the cranial 
prosthesis you purchased. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to reimburse you for a wig 
(A9282) purchased May 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on June 27, 2023. 
 
You asked the Plan to pay for the drug testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the drug testing 
provided on June 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown - porcelain/ceramic tooth #29 (D2740), core 
buildup, including any pins when required tooth #29 (D2950), and unspecified adjunctive procedures, by report 
(D9999) provided on June 6, 2023, and June 21, 2023.  
 
You asked the Plan to pay for the dental services. You say that you have submitted the narrative from the 
dental office which explains x-rays were taken prior to the core buildup and crowns for tooth 5 and 29. You 
also say that you have submitted your out-of-pocket expense which is to be reimbursed for the procedures. The 
Plan denied your request. The Plan says your benefit for the crown and core buildup has already been 
exhausted. The Plan also says the unspecified adjunctive procedure, by report is not a covered benefit 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, certain limitations apply. The record 
shows your benefit for the requested crown and core buildup was exhausted on date of service June 6, 2023. 
Therefore, we decided that the Plan does not have to pay for the crown - porcelain/ceramic tooth #29 (D2740), 
core buildup, including any pins when required tooth #29 (D2950) provided on June 6, 2023.   
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the unspecified adjunctive procedure, 
by report is not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the unspecified adjunctive procedure, by report (D9999) provided on June 21, 2023.