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

 
We decided that the Plan does not have to pay more for an extraction (D7210) for tooth #5 provided by an out-
of-network provider on May 4, 2023. 
 
You asked the Plan to pay more for the dental service. You say that the balance that you are being billed for 
should not be your responsibility. 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.  
 
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 amount billed for the extraction (D7210) for tooth #5 was $405 and the total allowed amount was 
$144 leaving a balance of $261 ($405 billed - $144 allowed). 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. Therefore, we decided that the Plan does not have 
to pay more for an extraction (D7210) for tooth #5 provided by an out-of-network provider on May 4, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve allograft, morselized, or placement of osteopromotive 
material, for spine surgery only (20930). 
 
You asked the Plan to pre-approve bone allograft. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the medical necessity for the requested procedure has not been established after 
clinical review per the peer-reviewed medical 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 bone allograft. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found osteopromotive allograft is experimental and investigational. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone allograft have not been met. Therefore, we decided that the Plan does not 
have to pre-approve allograft, morselized, or placement of osteopromotive material, for spine surgery only 
(20930).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 19, 2023, billed with 
procedure code 95165 (20 units). 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 95165 is professional services for the supervision of 
preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number 
of doses). 
 
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 the practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that documentation does not support the 
administration of 95165 of 20 units. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on April 19, 2023, billed with procedure code 
95165 (20 units).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care dressing (A6196 and A6212) provided on 
September 30, 2022. 
 
You asked the Plan to pay for wound care dressing (A6196 and A6212). You say that the items should be 
covered. 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 wound care dressing 
(A6196 and A6212) provided on September 30, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service May 3, 2023.  
 You asked the Plan to pay for procedure code 76642. You say that the claim was billed with the same code and 
different modifiers. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76642 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76642 billed for date of 
service May 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint and sacroiliac joint injections. 
 
You asked the Plan to pre-approve facet joint and sacroiliac joint injections. You say that this is medically 
necessary. The Plan denied your request. The Plan says this is not medically necessary. 
 
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 facet joint and sacroiliac joint 
injections. Our reviewer says that the service is not medically necessary. Our physician reviewer found that no 
imaging has been performed to determine facet hypertrophy exists, or if there is another pain generator. The 
plan to perform both the facet and sacroiliac joint injections is not standard of care. Doing both will not allow 
for the diagnosis of which is the actual pain generator. Therefore, the request is deemed not medically 
reasonable and 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 facet joint and sacroiliac joint injections have not been met. Therefore, we 
decided that the Plan does not have to pre-approve facet joint and sacroiliac joint injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the two calf rests/pads, replacement only (E0995 x2). 
 
You asked the Plan to pre-approve the calf rests/pads. You say that it is imperative that a power tilt be on the 
patient's group 3 power chair for maneuvering thresholds in their home, assistance with transfers, reposition 
and pressure offloads. The Plan denied your request. The Plan says calf pads are unbundled from the requested 
wheelchair. The Plan also says that code E0995 is for replacement items and replacement items cannot be 
approved with initial issue 
 
The Plan must follow Medicare rules. Medicare rules say that code E0995 is included in the allowance for code 
K0856 when provided at the same time. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the calf rests/pads have not been met. Therefore, we decided that the Plan does not have to pre-
approve the two calf rests/pads, replacement only (E0995 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stereotactic Body Radiation Therapy (SBRT) (77370, 
77373). 
 
You asked the Plan to pre-approve SBRT. You say that SBRT is medically necessary for the enrollee. The Plan 
denied your request. The Plan says there is no good evidence the SBRT treatment is safe or effective for the 
enrollee's cancer. SBRT 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 SBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found SBRT, delivering high fractional doses in 3-5 fractions is an established approach for the 
treatment of discrete lesions from cancer. For metastatic disease, SBRT is generally indicated for enrollees with 
oligometastatic disease of for those undergoing palliation after prior radiation to the same site. There is an 
important clinical distinction between the status of enrollees described above and an enrollee with widely 
metastatic disease for whom palliation is the major objective. In one setting, an enrollee with limited metastatic 
disease and good performance status is treated with the intention of eradicating all known active disease or 
greatly reducing the total disease burden in a manner that can extend progression free survival. For such an 
enrollee, SBRT can be a reasonable therapeutic intervention. Based on American Society for Therapeutic 
Radiology and Oncology (ASTRO) model policy, routine use of SBRT for palliation of spine metastases in the 
setting of more widespread disease is not in accordance with accepted standards of medical practice. The 
decision is therefore unfavorable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Stereotactic Body Radiation Therapy (SBRT) (77370, 77373).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 17, 2023, billed with 
codes 87481, 87500, 87640, 87652, and 87798. 
 
You asked the Plan to pay for the genetic testing billed. You say that the codes are payable. 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 NGS panel test was not billed with a single 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 May 17, 
2023, billed with codes 87481, 87500, 87640, 87652, and 87798.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the oxygen concentrator (E1390) provided 
on April 11, 2023, to May 11, 2023. 
 
You asked the Plan to waive the coinsurance for the oxygen concentrator (E1390). You say that the item should 
be covered. 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 20% 
coinsurance for durable medical equipment. 
 
You have been asked to pay 20% coinsurance for the oxygen concentrator (E1390). This item/service falls 
within the durable medical equipment 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. Therefore, we decided that the Plan does not have to waive the coinsurance for 
the oxygen concentrator (E1390) provided on April 11, 2023, to May 11, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic scanning computerized 
imaging provided on June 12, 2023. 
 
You asked the Plan to waive the copayment for the diagnostic scanning computerized imaging. You say that 
you paid the $15 copayment but was not told about the additional $30 copayment. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for other outpatient diagnostic tests during an office visit.  
 
 
 You have been asked to pay a $30 copayment for the diagnostic scanning computerized imaging. This service 
falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. The 
diagnostic scanning computerized imaging is considered a outpatient diagnostic testing. 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. Therefore, we decided that the Plan 
does not have to waive the copayment for the diagnostic scanning computerized imaging provided on June 12, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service May 5, 2023.   
You asked the Plan to pay for procedure code 88341. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
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.  
 
In this case, the MUE for CPT code 88341 is 13. The MAI value for this code is 3. You billed 14 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 88341 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88341 billed for date of service May 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit evaluation provided on May 30, 2023, by an 
OON provider.  
 
You asked the Plan to pay for a home visit evaluation. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service 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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 home visit evaluation provided on May 30, 
2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton treatment delivery; complex (77525x30). 
 
You asked the Plan to pre-approve proton treatment delivery. You say that you are requesting reconsideration 
for the denied services. The Plan denied your request. The Plan says a review of the literature indicates that 
proton beam radiation treatment (PBRT) is not the standard of care for pancreatic cancer. 
 
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 proton treatment delivery. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found provided medical records and review of the current peer-reviewed medical literature 
do not document that use of PBRT has been shown in controlled studies in a Centers for Medicare and 
Medicaid Services (CMS)-approved journal to result in long term health benefits in enrollees with 
adenocarcinoma of the head of the pancreas. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton treatment delivery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve proton treatment delivery; complex (77525x30).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee cannot safely go home at 
this time and there is not a lower-level facility that can accommodate the required needs. The Plan denied your 
request. The Plan says the enrollee is receiving appropriate inpatient acute care and is currently unstable for 
transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate at this time.  
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that a LTACH level of care is the most 
appropriate level of care for the enrollee to achieve the best outcome due to their complex medical needs. The 
Plan denied your request. The Plan says when the enrollee is ready to leave the hospital, they can receive this 
care in another setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. Given there are offered alternatives, 
LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic shoes provided on February 9, 2023. 
 
You asked the Plan to pay for the diabetic shoes. You say that you did not know the claim needed to be filed 
within 120 days. The Plan denied your request. The Plan says the claim was received after 120 days from the 
date of service. 
 
Medicare generally does not cover supplemental benefits. 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 that a claim for the diabetic shoes was not filed until July 17, 2023. This means that more 
than 120 days from the date of service had passed before a claim was filed. Therefore, we decided that the Plan 
does not have to pay for the diabetic shoes provided on February 9, 2023.