Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve periodontal scaling and root planing-four or more teeth per 
quadrant  (D4341 x 4). 
 
You asked the Plan to pre-approve these dental services. You say that you are requesting a reconsideration of 
the Plan's denial. The Plan denied your request. The Plan says that the requested services are 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 Plans coverage rules apply in this case. The Plan covers these dental 
services when 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 these dental services. Our reviewer says 
that the requested dental services are medically necessary. Our physician reviewer found that a review of the 
documentation indicates the presence of pathologic periodontal pockets (4-6mm) around four or more teeth per 
quadrant with areas of bone loss. Periodontal scaling and root planing is medically reasonable and necessary to 
treat your periodontal disease in all four quadrants. The documentation provided meets the criteria for coverage 
of periodontal scaling and root planing services.  
 
We looked at this physician's review, the file, and the Plans rules. Based on this information, we decided that 
the Plan's rules for coverage of these dental services have been met. Therefore, we decided that the Plan has to 
pre-approve periodontal scaling and root planing-four or more teeth per quadrant  (D4341 x 4).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87641, and 87653, billed for date of 
service October 18, 2022. 
 You asked the Plan to pay for procedure codes 87481, 87641, and 87653. The Plan denied your request. The 
Plan says payment for codes 87481, 87641, and 87653 is bundled into payment for code 87801. 
 
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 codes 
87481, 87641, and 87653 are column II codes to column I code 87801. This claim has not been billed with an 
appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 87481, 87641, and 87653, 
billed for date of service October 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code A4215 billed for date of service January 5, 2023. 
 
You asked the Plan to pay for code A4215. The Plan denied your request. The Plan says code A4215 is not 
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 code A4215 has a status indicator of X on the Physician Fee Schedule. This means that code 
A4215 is not covered. Based on this information, we decided that Medicare rules for coverage of code A4215 
have not been met. Therefore, we decided that the Plan does not have to pay for code A4215 billed for date of 
service January 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on January 26, 2023. 
 
You asked the Plan to pay for lab testing. You say that you say that the members labs were sent to you and 
therefore, the member is not using out of network benefits. 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 lab testing provided on 
January 26, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (99285) provided on November 
22, 2022. 
 
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 this claim is a duplicate of a previously paid claim and was 
correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on January 27, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for 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 November 22, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a porcelain/ceramic dental crown for tooth number 2 (D2740).  
 
You asked the Plan to pre-approve this dental item. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says that the requested dental item 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 Plans coverage rules apply in this case. The Plan covers this dental 
item when 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 this dental item. Our reviewer says that 
the requested dental item is medically necessary. Our physician reviewer found that a review of the 
documentation provided indicates that a crown was lost from tooth number 2. This crown had been in place for 
twenty years and the tooth is an abutment for a partial denture. It is medically reasonable and necessary to 
place a new crown on tooth number 2. The documentation provided meets the criteria for coverage of a 
replacement crown for this tooth. 
 
We looked at this physician's review, the file, and the Plans rules. Based on this information, we decided that 
the Plan's rules for coverage of this dental item have been met. Therefore, we decided that the Plan has to pre-
approve a porcelain/ceramic dental crown for tooth number 2 (D2740).   
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA test (81479) provided on February 3, 2023. 
 
You asked the Plan to pay for the PrismRA test. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says the requested test does not meet requirement for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. The DEX database shows that PrismRA is not covered. Based on this information, we decided that Medicare rules for coverage of the PrismRA test have not been met. Therefore, 
we decided that the Plan does not have to pay for the PrismRA test (81479) provided on February 3, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zioptan. 
 
You asked the Plan to pre-approve Zioptan. You say that you are requesting a formulary exception for Zioptan. 
You also say that the enrollee has tried numerous prostaglandins in the past and may be sensitive to those 
preservatives. 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 Zioptan.  
 
Benefits for Zioptan 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the request is not medically necessary because the 
records show that the ordered settings for the noninvasive ventilator can be delivered by a bi-level PAP 
machine with AVAPS capability. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure consequent to thoracic restrictive disease. Provided records document that the home 
ventilator is being requested for use in average volume assured pressure support (AVAPS) mode with auto-
EPAP (AE) which could be provided by a bilevel positive airway pressure (BiPAP) device with AVAPS and a 
back-up rate. Provided records do not document trial and failure of a BiPAP device with AVAPS and a back-up 
rate. As stated in the Local Coverage Determination (L33800): "Ventilators fall under the Frequent and 
Substantial Servicing (FSS) payment category, and payment policy requirements preclude FSS payment for 
devices used to deliver continuous and/or intermittent positive airway pressure, regardless of the illness treated 
by the device. (Social Security Act 1834(a)(3)(A)) This means that products currently classified as HCPCS 
code E0465, E0466, or E0467 when used to provide CPAP or bi-level PAP (with or without backup rate) 
therapy, regardless of the underlying medical condition, shall not be paid in the FSS payment category. A 
ventilator is not eligible for reimbursement for any of the conditions described in this RAD LCD even though 
the ventilator equipment may have the capability of operating in a bi-level PAP (E0470, E0471) mode. Claims 
for ventilators used to provide CPAP or bi-level CPAP therapy for conditions described in this RAD policy will 
be denied as not reasonable and necessary." The LCD requires: "There must be enough detailed information in 
the medical record to justify the treatment selected." Provided records in this case do not provide adequate 
detailed information to meet Medicare criteria for coverage of a ventilator as opposed to a BiPAP device with 
AVAPS and a back-up rate.  
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20930 and 20936 billed for date of service 
December 21, 2022. 
 
You asked the Plan to pay for procedure codes 20930 and 20936. You say that you have provided medical 
records to support payment. The Plan denied your request. The Plan says procedure codes 20930 and 20936 are 
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 codes 20930 and 20936 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes 20930 and 20936 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 20930 and 20936 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 20930 and 20936 billed for date of service 
December 21, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five additional physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the enrollee is not able to perform daily 
living activities without assistance. The Plan denied your request. The Plan says 5 visits have been approved, 
and the remaining 5 visits remain denied as not reasonable or necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that in this case, the enrollee has previously been treated with 
outpatient therapies and should be independent with a home exercise program. There is no documentation of a 
recent injury or decline in function. The additional therapy services are not an appropriate duration and 
frequency for treatment of the enrollees medical condition and therefore are 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 the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve five additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on November 9, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the claim for this 
molecular pathology testing did not include the required unique identifier. 
 
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 does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the testing provided on November 9, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal procedure. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says a review of the current medical literature indicates that this service is considered 
experimental and investigational as it is not identified as widely used and generally accepted for the proposed 
use as reported in nationally recognized peer-reviewed medical literature published in the English language. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that dynamic flexion/extension films are not provided in order to potentially assess the amount 
of movement (instability) at the requested surgical level. Detailed documentation is not evident regarding potential impending/inevitable temporary intra-operative instability. No compelling rationale is presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested posterior lumbar interbody fusion (PLIF) at L5-S1, in this case, 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 the procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a spinal procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 8, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on July 8, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. You say that given that antiresorptive will fail to reach target T-
scores, the enrollee will need anabolic therapy to reach target T-scores. You also say that to get the most out of 
anabolic therapy, it is imperative that it is used prior to antiresorptive therapy. The Plan denied your request. 
The Plan says that because the Plan's criteria have not been met and your provider has not demonstrated that it 
is medically necessary to make an exception for you, this request is not approved. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Evenity. Our reviewer says that Evenity 
is medically reasonable and necessary for the enrollee. Our physician reviewer found the record indicates that 
the enrollee has a diagnosis of postmenopausal osteoporosis at high risk for fracture and with a history of 
compression fracture. The FDA has stated that the requested drug is indicated for the enrollee's condition. Our 
reviewer found that the elements of the coverage criteria are satisfied. Our physician reviewer also found that 
the requested service is 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 Evenity have been met. Therefore, we decided that the Plan has to pre-approve 
Evenity.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rubraca (C9399). 
 
You asked the Plan to pre-approve Rubraca. 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 Rubraca (C9399).   
Benefits for Rubraca 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 28, 2022, billed 
with codes 81272, 81314, and 81345. 
 
You asked the Plan to pay for the genetic testing billed. 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 28, 2022, billed with codes 81272, 81314, and 81345.