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

 
We decided that the Plan does not have to pay for a limited oral evaluation and occlusal adjustment (D0140, 
D9951) provided on May 13, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental 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. 
 
 
  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 a limited 
oral evaluation and occlusal adjustment (D0140, D9951) provided on May 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation and intraoral x-ray (D0150, 
D0210) provided on April 5, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 item or service was exhausted on date of service November 17, 2022. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation and intraoral x-
ray (D0150, D0210) provided on April 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99223 and 99233 billed for dates of service 
from December 5, 2022, to December 7, 2022. 
 
You asked the Plan to pay for procedure codes 99223 and 99233. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says the provided records do not support the services 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223 is: Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components:  comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 
The definition of code 99233 is: Subsequent hospital care, per day, for the evaluation and management of a 
patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed 
examination; Medical decision making of high complexity. Counseling and/or coordination of care with other 
physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the 
problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a 
significant complication or a significant new problem. Typically, 35 minutes are spent at the bedside and on the 
patient's hospital floor or unit. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 99223 and 99233. Our reviewer says that 
procedure codes 99223 and 99233 do not meet criteria for payment. Our reviewer found that the documentation 
does not support a comprehensive history and medical decision making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 99223 and 99233 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 99223 and 99233 billed for dates of service from 
December 5, 2022, to December 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve a bone marrow aspirate. You say that this is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the setting of 
spinal 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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate is experimental. 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 a bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a bone marrow aspirate (20939).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the left L5-S1 radiofrequency ablation (RFA) procedure 
provided on December 2, 2022. 
 
You asked the Plan to pay for the left L5-S1 RFA. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services rendered are not covered. 
 The Plan follows Medicare rules. Medicare rules say that radiofrequency ablation is only covered for certain 
indications. 
 
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 pay for the left L5-S1 RFA. Our reviewer says that 
the documentation does not support that the services rendered were medically reasonable or necessary. Our 
physician reviewer found the enrollee has sacro-iliitis. The enrollee had diagnostic blocks of the lateral sacral 
branches which provided greater than 50% pain relief. The enrollee had RFA of the lateral sacral branches. 
This is considered an experimental procedure because of the wide variation in efficacy as published in the peer 
reviewed literature. Therefore, the enrollee did not meet criteria for the services rendered. 
 
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 left L5-S1 RFA have not been met. Therefore, we decided that the Plan does 
not have to pay for the left L5-S1 radiofrequency ablation (RFA) procedure provided on December 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cervical decompression surgery. 
 
You asked the Plan to pre-approve cervical decompression surgery. You say that the member is in pain and 
needs this procedure. The Plan denied your request. The Plan says records do not show that the MRI 
demonstrates cord compression. 
 
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 cervical decompression surgery. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the magnetic resonance imaging (MRI) does not show severe spinal 
stenosis at any level. There is also no correlation with a physical exam. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cervical decompression surgery have not been met. Therefore, we decided that 
the Plan does not have to pre-approve cervical decompression surgery.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L2 and L4 kyphoplasty (22514, 22515). 
 
You asked the Plan to pre-approve L2 and L4 kyphoplasty. You say that this is medically necessary. The Plan 
denied your request. The Plan says medical necessity coverage criteria are not met. 
 
 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 L2 and L4 kyphoplasty. Our reviewer 
says that the enrollee does not meet criteria for coverage. Our physician reviewer found the L2 fracture has 
retropulsion on imaging and there is no trial of bracing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L2 and L4 kyphoplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve L2 and L4 kyphoplasty (22514, 22515).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for new eye examination and treatment (92004) 
provided on January 30, 2023. 
 
You asked the Plan to waive the deductible for new eye examination and treatment (92004). You say that you 
were told this provider was in-network when you went to him on January 30, 2023. 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. Your 
contract with the Plan says that there is a $1000 deductible which applies to non-Medicare covered eye 
examination and each follow-up diabetic eye examination.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the non-Medicare covered eye 
examination and each follow-up diabetic eye examination benefit category. The Plan has followed Medicare 
rules by clearly disclosing in the contract that there is a $1000 deductible which applies to non-Medicare 
covered eye examination and each follow-up diabetic eye examination. This cost sharing is a contractual 
obligation that had not been met at the time new eye examination and treatment (92004) was received on 
January 30, 2023. Therefore, we decided that the Plan does not have to waive the deductible for new eye 
examination and treatment (92004) provided on January 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for COVID-19 test kits provided March 7, 2023. 
 
You asked the Plan to pay for COVID-19 test kits. You say that you filed a request for reimbursement for 3 
COVID-19 test kits that you purchased. You also say you received partial payment, and find it hard to believe 
that the Plan would not reimburse you for the full amount. The Plan denied your request. The Plan says the 
benefit maximum for this time period has been reached. 
 
The Plan must follow Medicare rules. Medicare rules say that they will cover up to eight over-the-counter 
COVID-19 tests each calendar month, at no cost to you. Medicare rules also say that enrollees cannot submit a 
claim for these tests to Medicare or their MA plan (unless covered by a supplemental benefit) for 
reimbursement under this initiative.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of COVID-19 test kit have not been met. Therefore, we decided that the Plan does not have to pay for 
COVID-19 test kits provided March 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assisted living facility services provided on April 12, 2023. 
 
You asked the Plan to pay for assisted living facility services. 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 assisted living facility 
services provided on April 12, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infusion services provided from March 29, 2023, to April 4, 
2023. 
 
You asked the Plan to pay for the infusion services. You say that the services were provided before the enrollee 
elected hospice. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services. The 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. 
 
We looked at the file and Medicare rules. The enrollee was under the Medicare hospice benefit for the dates of 
service at issue in this appeal. We also decided that there is insufficient information in the record to determine 
if Medicare rules for coverage of the infusion services have been met. In this case, the original claim billed a 
date range with multiple units instead of billing each date of service separately. There is no way to determine 
what has been billed for the dates of service that can be covered by the Plan. Therefore, we decided that the 
Plan does not have to pay for infusion services provided from March 29, 2023, to April 4, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95937 billed for date of service March 29, 
2023. 
 
You asked the Plan to pay for procedure code 95937. You say that this service is supported as billed. The Plan 
denied your request. The Plan says this code is not supported in the medical record. 
 
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 95937 is neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 95937. Our reviewer says that medical 
documentation does not support the use of procedure code 95937. Our reviewer found train-of-four monitoring is bundled with the intraoperative neuromonitoring of electromyography (EMG) or motor evoked potentials 
(MEP) and, therefore, is not separately reportable. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 95937 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 95937 billed for date of service March 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a limited oral evaluation and intraoral x-ray (D0220, 
D0140) provided on March 28, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the charges. 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. 
 
 
  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 a limited oral evaluation and intraoral x-ray 
(D0220, D0140) provided on March 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electronic connection between 2 or more power systems 
(E2311) expandable controller (E2377) and harness (E2313). 
 
You asked the Plan to pre-approve the upgraded electronics. You say that the medical records provided support 
the necessity of the requested services. The Plan denied your request. The Plan says the upgraded electronics 
are not medically necessary as there is not a medical need to control these power options through the joystick. 
 
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 upgraded electronics. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has Multiple sclerosis (MS) with impaired strength in the right upper 
extremity and both lower extremities and has 4/5 strength in the left upper extremity. The upgraded electronics 
are not medically necessary as the enrollee has sufficient strength and function in upper extremities to manage 
standard power drives. 
 
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 upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve electronic connection between 2 or more power systems (E2311) expandable 
controller (E2377) and harness (E2313).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve a continuous glucose monitor. You say that the enrollee has a history of one 
level 3 hypoglycemic event. The Plan denied your request. The Plan says that coverage criteria have not been 
met.  
 
The Plan must follow Medicare rules. The rules say that therapeutic continuous glucose monitors may be 
considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 a continuous glucose monitor. Our 
physician reviewer found that the enrollee has a history of severe low blood glucose readings. The enrollee was 
admitted to the hospital in July for this. Since then, the enrollee has had Glimepiride discontinued. He remains 
on Janumet. Although it is unlikely that the enrollee will be having anymore low blood glucose readings now 
that he is no longer taking glimepiride, the criteria allow for continuous glucose monitor use if there is a history 
of a severe low blood glucose readings. Due to the enrollees severe low blood glucose reading, it is reasonable 
to allow a continuous glucose monitor in this case, especially since his medication will likely be adjusted. 
 
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 continuous glucose monitor have been met. Therefore, we decided that the 
Plan has to pre-approve a continuous glucose monitor.  
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cala Trio device (K1018 and K1019 x 6). 
 
You asked the Plan to pre-approve a Cala Trio device. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
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 Cala Trio device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is insufficient evidence in the literature that this device is effective for the 
enrollee's tremors. The requested device is not the standard of care for this enrollee's tremor according to 
current guidelines.  
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 Cala Trio device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Cala Trio device (K1018 and K1019 x 6).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service August 3, 
2022, to September 1, 2022. You asked the Plan to pay for the billed services. You say that the services were deemed medically necessary. 
The Plan denied your request. The Plan says the NOA was not received timely.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is August 3, 2022. The NOA was not received by the Plan until February 16, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health care billed for 
dates of service August 3, 2022, to September 1, 2022.